2023 Walk Registration Info 2024 Walk for the Mind Registration Name(Required) First Last Address(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Email(Required) Phone(Required)Waiver(Required)RELEASE AND WAIVER: In consideration of the acceptance of my entry for Mark Linder Walk for the Mind, I hereby for myself, my heirs, executors and administrators, fully and forever RELEASE, REMISE, ACQUIT AND DISCHARGE the University of Illinois Foundation, University of Illinois College of Medicine, the Peoria Park District, RiverPlex, the City of Peoria and the Mark Linder Walk for the Mind (including, but not limited to, any volunteers, organizers, agents, servants, sponsors) and each of their officers, directors, agents and employees from any and all claims, demands, damages, actions or rights of action of whatever kind or nature I may now have or may hereafter have arising out of or in consequence of all known or unknown injuries to person or damages to property resulting to me in any way from my participation in the Mark Linder Walk for the Mind. I also grant permission to all the foregoing to use any photographs, motion pictures, recordings or other records of this event for any legitimate purpose. THIS RELEASE MUST BE SIGNED TO PARTICIPATE IN THE WALK. I agree to the Waiver.Walker/ Survivor Name1(Required) Choose:(Required) Walker Survivor Select Adult/Child/Survivor1(Required)Adult S-XL - $25Adult 2X, 3X - $28Child - $15Adult Size1(Required) Small Medium Large XL No Shirt Child Size1(Required) Medium youth No Shirt Adult Size1 2X-3X(Required) Adult 2x Adult 3x Survivor Adult-Child Size1(Required)Survivor Adult SmallSurvivor Adult MediumSurvivor Adult LargeSurvivor Adult XLSurvivor Adult 2XSurvivor Adult 3XSurvivor Youth MediumNo ShirtOnline User Fee1(Required) Price: Check to add another participant2 Check to add another participant2 Walker/Survivor Name2(Required) Choose2(Required) Walker Survivor Select Adult/Child/Survivor2(Required)Adult S-XL - $25Adult 2X, 3X - $28Child - $15Adult Size2(Required) Small Medium Large XL No Shirt Child Size2(Required) Medium youth No Shirt Adult Size2 2X-3X(Required) Adult 2x Adult 3x Survivor Adult-Child Size2(Required)Survivor Adult SmallSurvivor Adult MediumSurvivor Adult LargeSurvivor Adult XLSurvivor Adult 2XSurvivor Adult 3XSurvivor Youth MediumNo ShirtOnline User Fee2(Required) Price: Waiver2(Required) I agree to the waiver above. Check to add another participant3 Check to add another participant3 Walker/Survivor Name3(Required) Choose3(Required) Walker Survivor Select Adult/Child/Survivor3(Required)Adult S-XL- $25Adult 2X, 3X - $28Child - $15Adult Size3(Required) Small Medium Large XL No Shirt Child Size3(Required) Medium youth No Shirt Adult Size3 2X-3X(Required) Adult 2x Adult 3x Survivor Adult-Child Size3(Required)Survivor Adult SmallSurvivor Adult MediumSurvivor Adult LargeSurvivor Adult XLSurvivor Adult 2XSurvivor Adult 3XSurvivor Youth MediumNo ShirtWaiver3(Required) I agree to the waiver above. Online User Fee3(Required) Price: Add another Walker/Survivor Check to add another participant4 Walker/Survivor Name4(Required) Choose4(Required) Walker Survivor Select Adult/Child/Survivor4(Required)Adult S-XL - $25Adult 2X, 3X - $28.00Child - $15Adult Size4(Required) Small Medium Large XL No Shirt Child Size4(Required) Medium youth No Shirt Adult Size4 2X-3X(Required) Adult 2x Adult 3x Survivor Adult-Child Size4(Required)Survivor Adult SmallSurvivor Adult MediumSurvivor Adult LargeSurvivor Adult XLSurvivor Adult 2XSurvivor Adult 3XSurvivor Youth MediumNo ShirtWaiver4(Required) I agree to the waiver above. Online User Fee4(Required) Price: Check to add another participant5 Check to add another participant5 Walker/Survivor Name5(Required) Choose5(Required) Walker Survivor Select Adult/Child/Survivor5(Required)Adult S-XL - $25Adult 2X, 3X - $28Child - $15Adult Size5(Required) Small Medium Large XL No Shirt Child Size5(Required) Medium youth No Shirt Adult Size5 2X-3X(Required) Adult 2x Adult 3x Survivor Adult-Child Size5(Required)Survivor Adult SmallSurvivor Adult MediumSurvivor Adult LargeSurvivor Adult XLSurvivor Adult 2XSurvivor Adult 3XSurvivor Youth MediumNo ShirtWaiver5(Required) I agree to the waiver above. Online User Fee5(Required) Price: Check to add another participant6 Check to add another participant6 Walker/Survivor Name6(Required) Choose6(Required) Walker Survivor Select Adult/Child/Survivor6(Required)Adult S-XL - $25Adult 2X, 3X - $28Child - $15Adult Size6(Required) Small Medium Large XL No Shirt Child Size6(Required) Medium youth No Shirt Adult Size6-2x,3x(Required) 2X 3X Survivor Adult-Child Size6(Required)Survivor Adult SmallSurvivor Adult MediumSurvivor Adult LargeSurvivor Adult XLSurvivor Adult 2XSurvivor Adult 3XSurvivor Youth MediumNo ShirtWaiver6(Required) I agree to the waiver above. Online User Fee6(Required) Price: Check to add another participant7 Check to add another participant7 Walker/Survivor Name7(Required) Choose7(Required) Walker Survivor Select Adult/Child/Survivor7(Required)Adult S-XL - $25Adult 2X, 3X - $28Child - $15Adult Size7(Required) Small Medium Large XL No Shirt Child Size7(Required) Medium youth No Shirt Adult Size7-2x,3x(Required) 2X 3X Survivor Adult-Child Size7(Required)Survivor Adult SmallSurvivor Adult MediumSurvivor Adult LargeSurvivor Adult XLSurvivor Adult 2XSurvivor Adult 3XSurvivor Youth MediumNo ShirtWaiver7(Required) I agree to the waiver above. Online User Fee7(Required) Price: Check to add another participant8 Check to add another participant8 Walker/Survivor Name8(Required) Choose8(Required) Walker Survivor Select Adult/Child/Survivor8(Required)Adult S-XL - $25Adult 2X, 3X - $28Child - $15Adult Size8(Required) Small Medium Large XL No Shirt Child Size8(Required) Medium youth No Shirt Adult Size8-2x,3x(Required) 2X 3X Survivor Adult-Child Size8(Required)Survivor Adult SmallSurvivor Adult MediumSurvivor Adult LargeSurvivor Adult XLSurvivor Adult 2XSurvivor Adult 3XSurvivor Youth MediumNo ShirtWaiver8(Required) I agree to the waiver above. Online User Fee8(Required) Price: Check to add another participant9 Check to add another participant9 Walker/Survivor Name9(Required) Choose9(Required) Walker Survivor Select Adult/Child/Survivor9(Required)Adult S-XL - $25Adult 2X, 3X - $28Child - $15Adult Size9(Required) Small Medium Large XL No Shirt Child Size9(Required) Medium youth No Shirt Adult Size9-2x,3x(Required) 2X 3X Survivor Adult-Child Size9(Required)Survivor Adult SmallSurvivor Adult MediumSurvivor Adult LargeSurvivor Adult XLSurvivor Adult 2XSurvivor Adult 3XSurvivor Youth MediumNo ShirtWaiver9(Required) I agree to the waiver above. Online User Fee9(Required) Price: Check to add another participant10 Check to add another participant10 Walker/Survivor Name10(Required) Choose10(Required) Walker Survivor Select Adult/Child/Survivor10(Required)Adult S-XL - $25Adult 2X, 3X - $28Child - $15Adult Size10(Required) Small Medium Large XL No Shirt Child Size10(Required) Medium youth No Shirt Adult Size10-2x,3x(Required) 2X 3X Survivor Adult-Child Size10(Required)Survivor Adult SmallSurvivor Adult MediumSurvivor Adult LargeSurvivor Adult XLSurvivor Adult 2XSurvivor Adult 3XSurvivor Youth MediumNo ShirtWaiver10(Required) I agree to the waiver above. Online User Fee 10(Required) Price: Tax Information: Registration fees are not tax deductible as charitable contributions for Federal Income Tax purposes.Donations - Only donations (not registrations) are credited to a team. See list of teams at https://marklinderwalkforthemind.org/team-descriptions. Yes No Team NameOnly donations are credited to the team. See list of teams at https://marklinderwalkforthemind.org/team-descriptions. Donation Amount MessageTotal Due Credit Card(Required)Credit Card American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Expiration Date Security Code Cardholder Name