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					Registration Form

                                                                                PARKINSON’S UNITY WALK
                                                                         Rond Terrace, Commonwealth Park East
                                                                              Sunday 28 August 2011
                                         Walk, Stroll or Roll for Parkinson’s
                                         This is Parkinson’s ACT’s inaugural walk. It is also our 25th birthday. Come along and
                                         celebrate with your family and friends.
                                         People from all walks of life will be raising awareness of and funds to help improve the
                                         quality of life of those affected by Parkinson’s.
                                         Participants can choose either the 4km or 2km walk or the short, short cut. Just walk or
                                         stroll as much as you wish – it is not a race.

REGISTER ONLINE www.unitywalk.com.au OR BY COMPLETING THIS FORM. PLEASE PRINT CLEARLY to ensure that your registration can be processed. Every
participant must complete a registration form (one form per participant). Return form to SHOUT Office, Pearce Community Centre or post to PO Box 717 Mawson, ACT 2617
                                                                                                                                 On the Day
Participant’s First Name: : _____________________Surname: ___________________________                                            9.30am Confirm registration – please come to the
Address: : ________________________________                                                                                      tent to have your name marked off
Suburb: : ______________________ State: ____________             Pcode: ____________                                             10.30am – warm up session
Email: : ________________________________                                                                                        11.00am – walk commences
                                                                                                                                 Midday – sausage sizzle
Phone (H): ____________          (W): ____________        Mobile____________
                                                                                                                                 1.00pm – cutting the 25th birthday cake
ENTRY FEES:                                          METHOD OF PAYMENT
Adults: $20.00                                       Enclosed please find (please tick one):
Child or student: 5-15Yrs $10
Children (0-5 years):     Free                       □ Cash                □ Cheque                              □ Debit my credit card as follows:
(optional) Team Name:
                                                     Please debit the amount of $____________ to my: □Visa                            □ MasterCard
If registering as a team each team
member must register separately.                     _ _ _ _/_ _ _ _/_ _ _ _/_ _ _ _                             Exp Date _ _/ _ _
Registrations close midday Wednesday,
24 August                                            Cardholder’s Name: ________________________________ Signature: _____________________
ALL PARTICIPANTS MUST READ AND SIGN THESE CONDITIONS:
I acknowledge and agree that I participate in the Parkinson’s Unity Walk & Fun Run at my own risk and that I am responsible for ensuring that I am adequately and appropriately prepared, both
physically and mentally, for the walk. If I have any health issues or concerns prior to or during the walk, I understand and agree that I should immediately seek and act upon appropriate medical
advice. In consideration of Parkinson’s ACT Inc permitting me to participate in this event, I release and indemnify Parkinson’s ACT Inc and all persons, organisations or corporations associated
directly or indirectly with the conduct of the event, from and against all claims, liabilities, injury, loss or damage I may suffer or incur arising from or connected with my participation in this
event. I grant full permission for the organisers and media to use photographs, film or video footage of me participating in the Parkinson’s Unity Walk/Fun Run and surrounding activities, for
promotion of this or similar events in the future or in relation to relevant fundraising.
Signature:   _______________________________                          (Parent or guardian to sign if walker under 18)
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PARKING AND TRANSPORT
Parking is free either in the Rond Terrace car park off Parkes Way or the car park off Constitution Avenue. If parking in the Constitution Avenue car parks you walk through the underpass under
Parkes Way and turn left to the Rond Terrace.
Buses:
Both the ACTON 938 bus and the 980 bus stop in Constitution Avenue near the underpass leading to Commonwealth Park and Rond Terrace. Maybe this will be your warm up walk! Check the
ACTON bus timetable or phone 13 17 10. The Deane’s bus on route 830 also stops in Constitution Avenue. Phone: (02) 6299 3722.
Walk distance:
Participants can choose either the 4km or 2km walks – or the short, short cut. The 4km route takes approximately 1 hour to complete at a leisurely pace. The Unity Walk is
not a race and if participants wish to stroll the course, that’s just fine. Just walk as far as you wish and at whatever pace you wish.
Is the route pram and wheelchair accessible?
The entire route (4km and a 2km) is wheelchair and stroller/pram accessible.
Food and Beverages:
You are welcome to bring your own picnic food or enjoy the sausage sizzle. All walkers are strongly advised to bring their own water.
What if it rains on the day?
The Parkinson’s ACT 2011 Unity Walk will go ahead rain, hail or shine! We hope for great weather on the day. Should the weather be less than perfect, we hope you can still
come along in a united show of support.
What if I am unable to attend?
Please be advised that no refunds will be given.
FUNDRAISING
Monies raised by your fundraising efforts are vital to enable us to improve the quality of life for all those affected by Parkinson’s including funding ongoing research.
Fundraisers are eligible for fantastic prizes. Remind your sponsors that donations over $2.00 are tax deductible.
Corporate sponsors and prizes are constantly being updated. Log on to www.unitywalk.com.au for up to date list.

Prizes will be awarded for the highest individual fund raiser and for the highest amount raised by a team. Be in the lucky draw for prizes if you
register and participate in the walk.
Prizes at time of printing include: Gym membership, fitness training and shopping vouchers. More prizes to come.

Our corporate sponsors




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SPONSORSHIP / FUNDRAISING FORM
Sponsorship / Fundraising Form PLEASE PRINT CLEARLY TO ENSURE THAT YOUR DONATIONS CAN BE PROCESSED
This form may be photocopied if you require more space. We accept cheques, Visa and Mastercard only

YOUR NAME:
YOUR ADDRESS:
PHONE NUMBER:
Have you registered for the Unity Walk?

You must register for this event. Registration fees help cover the cost of this event. All prices are GST inclusive.
Please enclorse your cheque/money order payable to Parkinson’s ACT Inc and mail to PO Box 717 Mawson ACT
2617.
Deadline for receipt of fundraising money 5pm, 15 September 2011 Please phone 02 6290 1984 or (02) 0409
446635 if you need help with this form.

Sponsor’s Full    Sponsor’s Address            Post    Cheque     Credit card number                  Exp        Signature   Amount   Receipt
Name                                           Code    No                                             date                            required
                                                                                                                                      Yes -

                                                                  _ _ _ _/_ _ _ _/_ _ _ _/_ _ _ _     _ _/ _ _                        No -
                                                                                                                                      Yes -

                                                                  _ _ _ _/_ _ _ _/_ _ _ _/_ _ _ _     _ _/ _ _                        No -
                                                                                                                                      Yes -

                                                                  _ _ _ _/_ _ _ _/_ _ _ _/_ _ _ _     _ _/ _ _                        No -
                                                                                                                                      Yes -

                                                                  _ _ _ _/_ _ _ _/_ _ _ _/_ _ _ _     _ _/ _ _                        No -
                                                                                                                                      Yes -

                                                                  _ _ _ _/_ _ _ _/_ _ _ _/_ _ _ _     _ _/ _ _                        No -
                                                                                                                                      Yes -

                                                                  _ _ _ _/_ _ _ _/_ _ _ _/_ _ _ _     _ _/ _ _                        No -
                                                                                                                                      Yes -

                                                                  _ _ _ _/_ _ _ _/_ _ _ _/_ _ _ _     _ _/ _ _                        No -
                                                                                                                                      Yes -

                                                                  _ _ _ _/_ _ _ _/_ _ _ _/_ _ _ _     _ _/ _ _                        No -
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                                                                  _ _ _ _/_ _ _ _/_ _ _ _/_ _ _ _     _ _/ _ _                        No -
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                                                                  _ _ _ _/_ _ _ _/_ _ _ _/_ _ _ _     _ _/ _ _                        No -
                                                                                                                                      Yes - No -
                                                                  _ _ _ _/_ _ _ _/_ _ _ _/_ _ _ _     _ _/ _ _
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Sponsor’s Full   Sponsor’s Address       Post    Cheque   Credit card number                Exp        Signature                 Amount   Receipt
Name                                     Code    No                                         date                                          required
                                                                                                                                          Yes -

                                                          _ _ _ _/_ _ _ _/_ _ _ _/_ _ _ _   _ _/ _ _                                      No -
                                                                                                                                          Yes -

                                                          _ _ _ _/_ _ _ _/_ _ _ _/_ _ _ _   _ _/ _ _                                      No -
                                                                                                                                          Yes -

                                                          _ _ _ _/_ _ _ _/_ _ _ _/_ _ _ _   _ _/ _ _                                      No -
                                                                                                                                          Yes -

                                                          _ _ _ _/_ _ _ _/_ _ _ _/_ _ _ _   _ _/ _ _                                      No -
                                                                                                                                          Yes -

                                                          _ _ _ _/_ _ _ _/_ _ _ _/_ _ _ _   _ _/ _ _                                      No -
                                                                                                                                          Yes -

                                                          _ _ _ _/_ _ _ _/_ _ _ _/_ _ _ _   _ _/ _ _                                      No -
                                                                                                                                          Yes -

                                                          _ _ _ _/_ _ _ _/_ _ _ _/_ _ _ _   _ _/ _ _                                      No -
                                                                                                                                          Yes -

                                                          _ _ _ _/_ _ _ _/_ _ _ _/_ _ _ _   _ _/ _ _                                      No -
                                                                                                                                          Yes -

                                                          _ _ _ _/_ _ _ _/_ _ _ _/_ _ _ _   _ _/ _ _                                      No -
                                                                                                                                          Yes -

                                                          _ _ _ _/_ _ _ _/_ _ _ _/_ _ _ _   _ _/ _ _                                      No -
                                                                                                                                          Yes -

                                                          _ _ _ _/_ _ _ _/_ _ _ _/_ _ _ _   _ _/ _ _                                      No -
                                                                                                       TOTAL AMOUNT

Receipts: Please collect a small receipt book from the SHOUT office if you are using this form and your sponsors want a receipt or you can collect
a receipt on the day. People who donate online automatically receive a receipt.

The Parkinson’s Unity Walk in the ACT is hosted by:




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