Announcing the American Council of the Blind of Texas, Inc. (ACBT)
2012 "Walk for Success" Walk-a-thon
Our Success Team will be comprised of members, family, friends and other supporters as we make plans to diligently accept donations and walk together on Saturday September 29, 2012 during the 34th Annual ACBT Conference hosted by the Dallas and Fort Worth chapters. Everyone can participate by having someone to walk in their place if they are unable to do so. In addition, if for any reason it is not feasible for you or a designated representative of your choice to join the “Walk for Success” in Dallas, we encourage you to take advantage of the Virtual Walk Option which provides flexibility and the opportunity for you or a representative of your choice to walk in your home town or any other suitable location. Some individuals may select a City Park, School or University Track, the Mall or another highly populated area they feel safe in.
You automatically become an “ACBT Success Partner” when you submit your ten dollar entry fee as you register for the Conference, and accept additional donations in support of ACBT raising funds to continue its commitment to organize activities that support its goal of advancing and enriching the quality of life for Texans who are blind or visually impaired through advocacy, education, awards, scholarships and support. In appreciation for your participation you become eligible to win one of the three Participant’s Drawings, as well as the possibility of receiving the First or Second place prize for raising the most funds. You will also have access to the Participant’s Refreshment Bar before and after the walk. Stay tuned for more details as we approach the event date.
Look forward to a fun filled time of socializing as we
Walk for Success!
2012 ACBT Walk Individual Entry Form
Dallas, Texas
September 29, 20127:00 a.m. to 8:30 a.m.
Yes, I will enter for a fee of $10.00
Name:______
Address:______
City:______State:____Zip: ______
Phone:______E-Mail:______
There are two options for participating in the ACBT Walk. You can be an onsite walker, indicating your participation at Brookhaven College in Dallas on Saturday, September 29th. The other option is to participate as a virtual walker. You may not even be attending the ACBT Conference, or may not be physically capable of participating, or have conflicting commitments during the actual walk, but still want to support the walk by signing up and seeking pledges to assist with this fundraiser. Be sure to check the appropriate box to let us know which category you wish to be listed in. A Virtual walker is still eligible to compete for an award or prize based on the amount they bring in.
Check one of the boxes Onsite Walker______Virtual Walker______
If you would like to walk with a volunteer or if you would be willing to serve as a volunteer, please checkthe appropriate boxes below for purposes of matching you up:
I need a volunteer______I would be glad to serve as a volunteer______
My walking pace is: Slow____ Moderate_____ Brisk______
Specify the Chapter or special interest affiliate that you wish your participation to be credited to, for purposes of determining affiliate award.
Special Interest Affiliate/Chapter______:
Make checks out to: American Council of the Blind of Texas or ACBT
Mail Form and Check to: American Council of the Blind of Texas
Attn: Shelia Derrick
Address: P.O. Box 24655Fort Worth, TX 76124
For more information contact: Kenneth Semien, Sr. Phone: (409) 866-5838
2012 ACBT WALK WAIVER AND RELEASE
I wish to participate in the 2012 ACBT walk. I understand that my execution of this Waiver and Release is a prerequisite for participation in the Event.
I agree to accept all risks associated with this Event including but not limited to falls, contact with other participants, and the condition of the walking surfaces, all such risks being known to and appreciated by me.
In consideration of your accepting my entry for this Event, I hereby, for myself, my heirs, executors, administrators, or anyone else who might claim on my behalf, covenant not to sue, and waive, release and discharge American Council of the Blind of Texas, Inc. its members, any and all sponsors, and all of their officers, agents, and authorized volunteers, with respect to any and all claims for damages for death, personal injury or property damage which I may have, or which may hereafter accrue to me as a result of my participation in the 2012 ACBT walk, even though this liability may arise from negligence or carelessness on the part of the persons or entities referred to in this paragraph or from dangerous or defective property or equipment owned, maintained, or controlled by any such person or entity.
I understand that I am solely responsible for my health and safety and that the course which participants will be walking will be, for the most part, unsupervised. I acknowledge that I am physically capable of safely participating in and completing this Event. If I am a parent or guardian signing on behalf of a person who is less than 18 years of age, I acknowledge that I am strongly encouraged to personally accompany and provide adult supervision for such person during the entire Event.
Should any portion of this Waiver and Release be judicially determined to be invalid, for any reason, such portion of this Waiver and Release shall be severable from the remaining portions herein and the invalidity, voidability, or unenforceability thereof shall not affect the validity, effect, enforceability, or interpretation of the remaining provisions of this Waiver and Release.
I have read this Waiver and Release and understand its contents. If I am under 18 years of age at the time of registration, my parent or legal guardian has reviewed this Waiver and Release and understands and consents to its terms, and authorizes my participation by his/her signature below. I am aware that this is a RELEASE OF LIABILITY and a contract between me and the persons and entities mentioned above and I sign of my own free will. Parent or guardian will need to sign if participant is under 18 years of age.
Print Name______Signature______Date______
American Council of the Blind –Texas, Inc.
Walkathon – ACBT Conference
September 29, 2012 – Dallas DoubleTree Hotel
Sponsor List
Walker’s Name______
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ACBT is a non-profit 501 (c) 3 organization Make check payable to ACBT