City of Jacksonville

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Mayor's Walk for Wellness Registration Form

Last Name

First Name

Address

City

State

Zip Code

Home phone

Work phone

E-mail

Date of Birth

Age

If you represent an organization, please list it here.

T-shirt size Small
Medium
Large
X-Large
XX-Large

In case of emergency, contact:

Name

Phone number

Relation

Waiver
In consideration of the foregoing, I, myself, my heirs, executors, and administrators waive and release all rights and claims for damages I may have against the City of Jacksonville and/or any of the sponsors and/or organizers of this event for any and all damages, demands, actions whatsoever which may arise as a result of my participation in this event. I attest and verify that I am physically fit and have conditioned myself for the completion of this event and my physical condition has been verified by a licensed medical doctor. Further, I grant full permission to any and all of the foregoing to use my likeness for any promotional purposes related to the event or for future events.
Accept Do not accept

Under Florida law, e-mail addresses are public records. If you do not want your e-mail address released in response to a public records request, do not send electronic mail to this entity. Instead, contact this office by phone or in writing.

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Last Name
First Name
Address
City
State
Zip Code
Home phone
Work phone
E-mail
Date of Birth
Age
If you represent an organization, please list it here.
T-shirt size	Small Medium Large X-Large XX-Large
In case of emergency, contact:
Name
Phone number
Relation
Waiver In consideration of the foregoing, I, myself, my heirs, executors, and administrators waive and release all rights and claims for damages I may have against the City of Jacksonville and/or any of the sponsors and/or organizers of this event for any and all damages, demands, actions whatsoever which may arise as a result of my participation in this event. I attest and verify that I am physically fit and have conditioned myself for the completion of this event and my physical condition has been verified by a licensed medical doctor. Further, I grant full permission to any and all of the foregoing to use my likeness for any promotional purposes related to the event or for future events. Accept Do not accept