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Reston Epilepsy Awareness Stroll

Greetings everyone, Come join the UCB Pharma Epilepsy Awareness Stroll Saturday November 10, 2007 Lake Fairfax Park, Reston, Virginia The Reston Epilepsy Awareness Stroll is sponsored by the Epilepsy Foundation of Virginia (EFVA). Questions? Call Dana Douglas at (703) 425-6660 or Kristen Cortes at (724) 944-7685 Registration Form: Name: _______________________________________ Address: _____________________________________ City: _________________________ State: _______ Zip: __________ Home Phone: ____________________ Work Phone: _____________________ E-mail: ____________________________________ (NOTE FOR WALKERS: You must sign the waiver on the following page, whether or not you’ll be collecting donations. Thanks!) Admission Free for Participants Free T-shirt for walkers donating $20.00 or more. If you’d like to make a donation, but do not wish to walk, please complete the form above, indicate the amount of your donation $__________. Mail this form, along with your donations (checks payable to EFVA), to: EFVA, P.O. Box 3235, Reston, Virginia 20195 2007 Epilepsy Awareness Stroll Pledge Form Registration starts at 9:00 am; Walk begins at 9:15 am. Directions: Lake Fairfax is located at 1400 Lake Fairfax Drive in Reston. Lake Fairfax Park may be reached by taking Beltway Exit 47A which is Route 7 (Leesburg Pike) west to a left on Baron Cameron Avenue to the second left on Lake Fairfax Drive. The telephone number at Lake Fairfax Park is 703-471-5415. Sponsor List: Ask friends, family, co-workers, and even strangers for donations to the Epilepsy Awareness Stroll. All contributions are tax-deductible to the extent of the law. Sponsor Name Sponsor Address Donation Amount $ $ $ $ $ $ $ TOTAL $ ________ Waiver: I, ________________________ (Name, Please Print) for myself, my heirs and executors, in consideration of any participation in the Epilepsy Awareness Stroll, hereafter called the Event, hereby releases, holds harmless and covenants not to sue the Epilepsy Foundation of Virginia and others connected with the Event, including the Epilepsy Foundation of America, municipalities, sponsors, and their directors, officers, employees, volunteers, or agents from any claims or damages or injuries which I may have or which I may suffer in connection with the Event. I give my consent to use my name likeness, voice or biographical information and any photos, photo recordings or videotapes taken or any publicity including me at the Event. Signature: ___________________________________(You must sign to participate) Parent or Guardian (if under the age of 18) I represent and warrant that I am the legal parent or guardian of the participant names listed and that I have read and fully understood the waiver release and agree for myself and the participant, participant’s heirs and representatives to be bound there by. Signature: ___________________________________


Re: Reston Epilepsy Awareness Stroll

And it's in my area. Cool!

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