Peace Walk 2025 Registration & Waiver

Peace Walk 2025 Registration & Waiver
Monday, January 20

Peace Walk & Hygiene Drive

Begins at Bethel AME Church, 601 Hepburn Street, Williamsport

Please bring a hygiene product to be donated to local agencies!
Participant Name*

First NameLast Name
Are you the parent/guardian of any participants under 18?*

YesNo
List children
I understand that Lycoming-Clinton Counties Commission for Community Action (STEP), Inc. will be held harmless for any and all claims of bodily injury or property damage that occurs while participating or volunteering during the MLK Day Peace Walk on January 20, 2025 or any other affiliated Dream Week 2025 service projects or events. I waive any claim for compensation or liability on the part of STEP including board members, committee members, AmeriCorps members and staff.

I grant and convey unto STEP all right, title and interest in any and all photographic images and video/audio recording made by STEP during my volunteer activities or participation on MLK Day Peace Walk on January 20, 2025 or any affiliated activities during Dream Week 2025.
Signature of Participant or Parent/Guardian*

Emergency Contact Information
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone*
Please enter a valid phone number.
Emergency Contact Phone #2*
Please enter a valid phone number.
Emergency Contact Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please describe any physical, medical, or other special circumstances you may have including allergies and essential medications: