2019 Suicide Prevention Day: Awareness Walk

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Suicide Awareness

Tuesday, September 10, 2019
David A Howe Library
Exhibit Hall
North Main Street
Wellsville, NY 14895

        Please Join Us:
        5:00pm - Registration, Resource Fair, Rayne Rocks' and Remembrance Quilt
6:00pm - Welcome
      6:15pm - Announcements and Guest Speakers
6:45pm.- Awareness Walk
        7:15pm - Lighting of the Candle
        7:30pm - Closing Remarks

Can't make the walk, but interested in supporting the Allegany County Suicide Prevention Coalition?

'Take the Pledge' Campaign: (optional)

Make a Difference and Help Support the Allegany County Suicide Prevention Coalition by Taking the Pledge! Take the Pledge to raise awareness about suicide risk factors and warning signs and help connect individuals with suicide prevention, intervention and postvention efforts. Monetary donations raised from Take the Pledge Campaign will support Suicide Prevention.

INSTRUCTIONS
1) Download the Take the Pledge Form
2) Ask friends, family members, co-workers, neighbors and others to pledge a donation in support of your participation in the Allegany County Suicide Prevention Walk
3) Collect funds prior to Sept. 10, 2019 and bring pledge forms & money to the event

Waiver: This waiver must be checked in order to participate in the World Suicide Prevention Day Awareness Walk.

Release and Waiver of Liability: In consideration for participating in the World Suicide Prevention Day Awareness Walk (“Walk”), I waive, release, and hold harmless Ardent Solutions and its, directors, officers, administrators, representatives, past and present employees, volunteers, agents, and supervisors, and also all participants, all city and state governments, all assigns, all sponsors, their representatives and successors and other persons (collectively, “Releases”) from any and all claims, liabilities, losses, demands, expenses, attorney fees, or causes of action arising out of an injury to me (or my child), and from any and all claims, liabilities, losses, demands, expense, attorney fees, or causes of action arising from my (or my child's) participation or attendance in the Walk. I assume all risks associated with participating or attending the Walk (including, but not limited to the risk of physical activity, collisions with other participants, falling, and any conditions of road surfaces). I assume complete responsibility for any injury or accident in which I (or my child) are a participant (and any resulting demands, expenses, and attorney fees) which may occur while traveling to or from the Walk, during the Walk, or while I (or my child) are on any premises related to the Walk. I agree to observe and obey all rules and safety procedures that accompany the Walk and to abide by any decision of a Walk official relative to my (or my child’s) ability to safely complete the Walk up to and including refusing participation in the Walk and returning the Walk registration entry. I am fully aware of the risks connected with participating in the Walk, whether specifically listed in this Release or not, and I voluntarily elect to participate in the Walk, or have my child participate in the Walk, knowing that participating involves these risks. I agree that the Releases are not responsible for any personal items or property lost or stolen or damaged before, during, or after the Walk.

Severability: I agree that if any portion of this Release is deemed to be invalid, the remainder of this Release shall still be binding and in full force and effect.

For Parents/Guardians of a Participant under the age of 18: I attest that I am in fact the parent or legal guardian of the minor participant participating in the Walk. I hereby give my approval to this child's participation and assume all risks to such participation as outlined above in the Release and Waiver of Liability. I attest that if my child, the above-named participant, is under fourteen (14) years of age as of the date of the Walk, he or she will be accompanied by an adult eighteen (18) years of age or older throughout his or her participation in the Walk.

Registration Form:

Please complete the following Registration Form. If a family, please include all participants on one registration form.

* Indicates required field

Adult Participant *

First

Last

Adult Participant (optional) *

First

Last

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Child Participant 1 (optional) *

First

Last

[object Object]

Child 1 Age: *

Child Participant 2 (optional) *

First

Last

Child 2 Age: *

Child Participant 3 (optional) *

First

Last

Child 3 Age: *

Address *

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Line 2

City

State

Zip Code

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Email *

Phone Number *

I am walking in memory/honor of: *

How many years have you participated in the World Suicide Prevention Day Awareness Walk: *

First Year Participating 2 Years 3 Years 4 Years 5 Years

How did you hear about the World Suicide Prevention Day Awareness Walk: *

Facebook Newspaper Email Announcement Website Family or Friend

Photography Release: I hereby consent that any and all still, electronic image, audio recording, or any other record now known or hereafter developed which records my (or my child’s) participation in the Walk, may be used, reproduced, published, or altered by Ardent Solutions without limitation. I understand that these materials may be used in news releases, promotions, web sites, educational materials, or for commercial purposes. I further agree that my, my child’s name, and identity may be revealed in descriptive text or commentary in connection with the material indicated in this section.

Photography Waiver: *

Accept Decline

Waiver Acceptance *

I acknowledge and represent that I have carefully read and understand all terms of this Release and Waiver of Liability. I accept the terms of the waiver for my child who is under 18 years of age

Submit

For further information, please email Patty Amidon or phone at 585-593-5223, ext. 1010.

Our Mission: To create synergy within and between systems, organizations, families, and individuals that result in a strong culture of health and quality services for our communities.

85 N. Main Street, Wellsville New York 14895 ● Phone: 585-593-5223 ● Fax: 585-593-5217