Life is Better When We Walk Together! Join Mississippi's Walk for Diabetes! PLEASE READ ME! If you are a team captain and wish to create an online fundraiser for your team, you should use the MightyCause platform found HERE instead of this form. That will allow your friends and family to easily donate to your team and forward to their friends. Create a "Fundraiser", not a "Team" unless you think your friends will be setting up competing fundraisers to support you. If you follow the link to MightyCause, be sure to scroll down to "Featured Campaigns" to choose the walk you wish to support so that location's walk gets credit for your team fundraiser!! If you are not forming a walk team and wish to register multiple walkers with a credit card without the hassle of doing it one by one, you may wish to call 601-957-7878 during regular business hours. Thank you for your support!!Choose the Walk You wish to support!(Required)Gulf Coast - March 4, 2023 - Jones ParkJackson Metro/Central MS - October 1, 2023 - Southern Farm Bureau LifeWalk Team / Team captain(Required)Please enter your walk team name or "Individual" if not part of an organized team. Walker Name(Required) First Last Walker Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Walker PhoneWalker Email My Personal Fundraising Goal Donation Levels(Required) Just the Walk - $25 Walk Registration, Walk T-Shirt $50 Walk Registration, Walk T Shirt and $10 Gift certificate $100 Super Walker The above plus our amazement and gratitude - $500 Amazing Walker The above plus our amazement and eternal gratitude - $1000 Rock to Lean on Walker The above plus possible sainthood- $2500 Walk Shirt Size for $50 or $100 Level Registration I waive my gifts. Please use my entire donation for your programs and services Child Small Child Medium Child Large Adult Small Adult Medium Adult Large Adult XL 2XL 3XL Contactless Waiver I have read and accept the following waiver for myself and/or as parent/legal guardian of a minor Mississippi’s Walk for Diabetes Release and Indemnification I understand that Mississippi’s Walk for Diabetes involves physical activity (walking, running, etc), which may include risks such as, but not limited to, falls, effects of weather, traffic and conditions of the road, and interactions with other participants. In consideration of being allowed to participate in this event, I hereby expressly assume all risks including personal injury, arising in any way out of my participation in the Walk for Diabetes and related activities. It is my responsibility to dress appropriately and bring any medical equipment or medications that I might require. I understand that although route maps, rest stops, refreshments, first aid and other assistance may be available during this event, I am solely responsible for my own health and safety. I agree to ask for assistance if I experience any symptoms or conditions which would make it difficult or unsafe to continue in the event. I agree for myself, my heirs, executors and administrators, not to sue and to release, indemnify and hold harmless, the Diabetes Foundation of Mississippi, Southern Farm Bureau Life Insurance Company, their officers, directors, volunteers and employees, and all other sponsoring businesses and organizations and their agents and employees, from all liability, claims, demands and causes of action whatsoever, arising out of my participation in this event and related activities-whether it results from the negligence of any of the above or from any other cause. This release and indemnification agreement shall be as broad and inclusive as is permitted by the State of Mississippi or city in which the event is conducted. If any portion of this release shall be held invalid under the laws of Mississippi, those parts not held invalid shall continue in full force and effect. If participant is a minor, parent or guardian must accept: I am the legal Guardian of the Walk Participant and hereby consent to his/her participation in Mississippi’s Walk for Diabetes. I have read the foregoing release and indemnification agreement, and I hereby agree to its terms on behalf of myself and Participant. Total $0.00 Billing Address(Required) Same as previous Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Credit Card(Required) American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Month010203040506070809101112 Year20232024202520262027202820292030203120322033203420352036203720382039204020412042 Expiration Date Security Code Cardholder Name Phone (associated with credit card owner)(Required)Email (associated with Credit Card Owner)(Required) CAPTCHACommentsThis field is for validation purposes and should be left unchanged.
