Please return to Kendra Hansen at Buffalo County Community Partners by Wednesday, May 2, 2018. Registrations received after May 2nd will not be guaranteed a t-shirt.

P.O. Box 1466
Kearney, NE 68848

Business or Organization

Company Name:

Address:

City:State:Zip:

Company Representative:

Phone:Email:

Participation

Total Number of Participants:

Shirt Count
Small / Medium / Large / XL / 2XL / 3XL / Total
Shirts
Cost Each / $6 / $6 / $6 / $6 / $8 / $9
Cost

There will be no onsite lunch. Lunch coupons will be distributed at UNK during the T-shirt pick up

Will your company walk at your worksite?YesNo

Would you like assistance in setting a route at yourworksite?YesNo

Payment Procedure

For accounting purposesBuffalo County Community Partners prefers one payment method from each organization. Upon receipt of this registration, Buffalo County Community Partners will invoice your business/organization for the total amount due for all participants.

Payments via check may be made payable to Buffalo County Community Partners.
If you choose to pay via credit card, please call us at 308-865-2284 to provide the information.

**All Credit Card payments will be assessed a $0.35 transaction fee plus a 2.9% processing fee**

Participant Rights and Waiver

By signing up to participate in Walk Out On Your Job, you and your employees waive and release all rights and claims for damages you may have against the organizers and sponsors of Walk Out On Your Job for any and all injuries suffered at this event. By signing up to participate, you and your employees authorize the organizers and support personnel of the event to obtain any appropriate medical aid should it be required during the event.

By signing up to participate in Walk Out On Your Job, you and your employees grant permission for pictures to be used in promotional materials by Buffalo County Community Partners. If you or any of your employees do not wish to grant this photo permission, please contact Buffalo County Community Partners prior to the event.

By signing up to participate in Walk Out On You Job, you and your employees give permission to be contactedvia email by Buffalo County Community Partners for follow-up questions about your experience participating in Walk Out On Your Job, mode of transportation and general physical activity level. There will be no solicitation from other parties and you will only receive emails relating to Walk Out On Your Job. This helps to provide data for the event and future planning of programs.

If you need help assessing participation at your worksite, feel free to utilize this sign-up sheet. Even if you use the sign-up sheet, you will still need to total your participants and shirt order on the registration page. This sign-up sheet is simply a tool to help you gauge participation. Thank you!

Name / Email / Shirt Size