Survey - DIY Fundraiser Application - American Parkinson Disease Association

1.

Fundraiser Information

*

Name:

First Required	Last Required

*

Email: Required

*

Street 1: Required

*

Street 2: Required

*

City/State/ZIP:

City Required	State Required	ZIP Required

*

Country: Required

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*2.

Question - Required - I am fundraising for APDA:

*3.

Question - Required - Short Description of Fundraiser (Bowling event, run/walk, karaoke night, cycling, etc.)

*4.

Question - Required - I certify that I have read the event waiver and release of liability in regard to the DIY fundraising opportunities and fully understand its terms. I understand that I am giving up substantial rights, including the right to sue, and I sign this document freely and voluntarily. Link to APDA DIY Event Waiver: https://qrco.de/APDAFundraiserWaiver

*5.

Question - Required - By typing your name in the "Participant Signature" space, you agree to the terms of this contract. Participant Signature:

*6.

Question - Required - Signature Date:

Month

Day

Year

7.

Question - Not Required - (If the participant is under 18) Parent/Guardian Name and Signature:

8.

Question - Not Required - Parent/Guardian Signature Date:

Month

Day

Year