Vendor Information

Organization or Individual Name(Required)

Preferred Name to Display on Promotional Materials(Required)

Email(Required)

Primary Phone Number(Required)

Alternate Phone Number

Correspondence Mailing Address(Required)

Street Address Address Line 2 City State ZIP Code

Day-of Contact Person(Required)

Day-of Contact Person Phone(Required)

Vendor Type and Payment

Vendor Type(Required)

Retail ($30 per Table)

UAMS Department (No Charge)

Non-Profit (No Charge)

Payment(Required)

Check

Credit Card by Phone

Invoice

501(c)3 number

Invoice

Please email an invoice to the email provided.

Please mail an invoice via USPS to the mailing address provided

Please remit payment with this form to:

UAMS Foundation Fund
4301 W Markham Street
Slot# 623-2
Little Rock, AR 72205
In Memo Line of Rock of check: BAPOTC Walk

For questions about gift in-kind donations and general Be A Part of the Cure Walk inquiries, contact the Winthrop P. Rockefeller Cancer Institute Special Events team
WPRCI-SpecialEvents@uams.edu or 501-686-6113.

Waiver and Photo Release Agreement

This release is only valid for the primary participant.

All participants before, during, or after the Be a Part of the Cure Walk for Cancer (“Event”), hereby expressly consent to the following:

I acknowledge and agree that participating in the event may be a potentially hazardous activity. I agree to participate at my own risk, and I agree to assume all risks associated with participating in the Event, including, but not limited to , falls, weather conditions, traffic, road conditions, and contact with other participants.
I understand that bicycles, skateboards, roller skates, roller blades or riding any similar apparatus is not allowed during the Event. This exclusion does not include wheelchairs.
In consideration of my acceptance into the Event, I for myself and anyone entitled to act on my behalf, hereby waive and release any and all claims, liabilities, damages (compensatory and punitive), legal fees, and causes of action that may arise as a result of my participating in the Event or any pre-Event/post-Event activities, that I may have or that I become aware of in the future, against persons, volunteers, and entities involved in planning, hosting or assisting with the Event, even if such liability may arise out of their negligence or carelessness, including but not limited to, the Event sponsors, the Board of Trustees of the University of Arkansas, the University of Arkansas for Medical Sciences, the University of Arkansas Foundation, Inc., and any of their trustees, directors, employees, members, representatives, successors and assigns.

I agree that this waiver and release applies to myself and my successors and assigns, heirs, and any executors, administrators, personal representatives or beneficiaries or others who may make a claim on behalf of my estate.

I grant full permission to use and reproduce my images or likeness by any audio and/or visual recording technique (including electronic/digital), for any legitimate purpose, including commercial marketing purposes, relating to the Event or to promote awareness and fundraising for cancer-related initiatives. I understand and agree that any ticket price/entry fee(s) paid to participate in the Event are non-refundable.

I have read and agree with the statements above.

By signing, you hereby expressly agree to the above for yourself, or for a minor if you are the parent/ guardian, as if signing your name.

Participant's Name(Required)

First Last

Are you signing up for a minor?(Required)

I am the legal guardian of the participant above

Does not apply to me

Legal Guardian's Name

First Last

All minors under the age of 13 must have a legal guardian present at the event.

Legal Guardian's Email

All minors under the age of 13 must have a legal guardian present at the event.

Group / Organization(Required)

school name, company, self, etc.

Emergency Contact(Required)

First Last

Emergency Contact Number(Required)

Purpose for Waiver(Required)

Entertainment

Volunteer

Other

Date(Required)

Signature(Required)

Type your full name