Individual Registration Form If you are not a member of a Team, upon receipt of this completed Registration Form, a Donation Envelope will be mailed to you. If you are a member of a Team, your Team Captain will give you a Donation Envelope after completion of this Registration Form. If you are a Team Captain, go to the Team Registration form and sign up your team! Sign up today, so Tomorrow will bring a cure, prevention & Treatment for this disease. Without You, It won't happen! Memory Walk Individual Registration Form Peachtree City October 1, 2011 Frederick Brown, Jr. Amphitheater

Name* Gender Male Female Age* Street Address* City* County* State* Zip Code* Home Phone Number* Email Address Member of team / team name: Choose your T-Shirt Size SmallMediumLargeXLargeXXLarge ALL REGISTRANTS MUST SIGN Waiver and Release of Liability: I hereby waive all claims against the Alzheimer's Association, sponsors or any personnel for any injury I might suffer in this event. I attest that I am physically fit and prepared for this event. I grant full permission for organizers to use photographs of me and quotations from me in legitimate accounts and promotions of this event. (Parent or Guardian's signature if less than 18 years of age. Please also print Guardian’s name.) Guardian I Agree Please enter the phrase as it is shown in the box above.