Toni Kenion
Nurse Practitioner/Owner, Concinnity Health Direct Primary Care
(919) 435-1185 (office) | (919) 435-8548 (fax)
www.concinnityhealth.org
t.kenion@concinnityhealth.org
258 Southtown Circle, Rolesville NC 27571
WALK
T-SHIRT
Every T-shirt purchased directly supports our mission to raise awareness, honor survivors and end sexual trauma.
Are you registering as
Parent/Guardian Consent — required only for minors: I am the parent/legal guardian of the minor listed above, and I give permission for the minor to participate in the Annual Molestation Survivor Walk.
Event Rules, Risk, and Liability Release
By registering, I understand and agree that participation in the Annual Molestation Survivor Walk is voluntary. I will follow all event rules, staff instructions, route directions, safety guidance, and posted signs. I understand that KYHOM INC may remove any participant for unsafe, disruptive, threatening, harassing, discriminatory, or inappropriate behavior.
I understand that participation may involve risks, including but not limited to walking outdoors, uneven surfaces, crowds, weather, traffic-related risks, illness, physical injury, emotional distress, property loss, or other unexpected incidents.
To the fullest extent permitted by law, I voluntarily assume all risks connected with my participation, attendance, travel to and from the event, and related event activities. To the fullest extent permitted by law, I release, waive, discharge, and hold harmless KYHOM INC, its directors, officers, employees, volunteers, organizers, representatives, partners, sponsors, vendors, agents, successors, and assigns from any claims, damages, losses, costs, or expenses arising out of or related to my participation or, if I am signing for a minor, the minor participant’s participation, except where prohibited by law.
For minor participants, I understand that laws regarding releases and waivers for minors vary by state, and this release applies only to the fullest extent permitted by applicable law. I have read, understand, and agree to the event rules, assumption of risk, and release of liability.
Photo and Media Release
KYHOM INC may take photos, videos, livestreams, interviews, or other recordings during the event for nonprofit outreach, education, social media, website content, newsletters, press, fundraising, event promotion, and future awareness campaigns.
Media Consent:
Final Signature
By signing below, I confirm that the information provided is true and complete. I understand that typing my name serves as my electronic signature.
I have read and agree to all required registration, consent, safety, risk, release, and signature terms.
