2011 No More Victims Walk / Registration Form

Note: Only one walker per form submission. All fields required (except Agency/Church). Thank you!


First Name:
Last Name:
Agency/Church (if any):
Street Address:
City:
State / ZIP: ,
Phone: ( )
Email:
Date of Birth (mm/dd/yy):

All Walkers Must Sign Waiver:

I agree to the waiver text printed below:

I hereby waive for myself, my heirs and my assigns, all claims against You Have the Power and the Tennessee Dept. of Correction for any and all injuries or illness that may result from my participation in this event. I attest that I am physically fit and have significantly trained for participation in this event. I hereby grant full permission to any and all photography, video, motion pictures or any recording ofthis event for any legitimate purpose. I understand that the walk goes, rain or shine, and that no refunds will be given. I herby certify that I am at least eighteen (18) years of age and anyone under the age of eighteen (18) is prohibited from participating in this event.

Enter security code shown below or [ ]


CODE HINT: number nine, lowercase "c", number six, uppercase "F", lowercase "x", lowercase "y"

Security Code:



Stay In The Know!Join Mailing List