Name *

First Name

Last Name

Name of Individual With Spina Bifida *

First Name

Last Name

Phone *

(###)

###

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Liability Waiver *

By checking this box, the individuals listed above absolve Spina Bifida of Greater St. Louis Inc. (15620 Manchester Rd., St. Louis, MO 63011) of any liability while attending this event.

Yes

Media Permission *

By checking this box, the individuals listed above grant permission to Spina Bifida of Greater St. Louis to use any video/photos taken at the Walk & Roll event.

Yes