Kohl's Step Up For Kids Registration

Adults: = $45 + $55 minimum fundraising commitment = $ 100
Kids (12 & Under) = Free

EVENT OPTIONS
  Participants:
Full climb (80 floors)          Half climb (38 floors)
  Registration Options:
Adult Registration: $100 (yes, I would like to personally donate the $55 minimum fundraising amount at this time)
Adult Registration: $45 (I do not wish to personally donate the $55 minimum fundraising amount at this time)
Child Registration (Under 12): Free

TEAM OPTIONS
Register as an individual
Join a Team     Team to join: 
Create a Team     New Team name: 

T-SHIRT SIZE
Adult: S M L XL XXL
Child: S M L

REGISTRANT INFORMATION
* = Required Field
First Name*
    M.I. 
Last Name*
Gender* Male     Female
Date of Birth*
/ /   MM/DD/YYYY
Home Address*
City, State ZIP*
,    
 
Phone*
Email Address*

How did you hear about this event?*

PAYMENT INFORMATION
Payment Total
Payment Method  Check   Credit card   Cash
Credit Card Type  Master Card    Visa    American Express    Discover  
Name on Credit Card 
Credit Card Number
Expiration Date
/
CVS Number

RELEASE AND WAIVER
A physical examination is not required for this event. However, all steppers participate at their own risk. If in doubt as to your physical condition, it is strongly recommended that you seek the advice of a competent physician. All persons under 18 years of age must have written consent of their parents or legal guardian to participate in the above-mentioned event. In consideration of my participation in Kohl's Step-Up for Kids, I, for myself, for my heirs, executors, administrators, successors and assigns hereby release and discharge the owners and managers of the Aon Center, Jones Lang LaSalle, Wells REIT, Kohl's Department Stores, all sponsors of this event, K.I.D.S.S. for Kids, Inc., Children's Memorial Hospital and all their respective officers, directors, employees, volunteers, agents and servants, from any and all claims, demand and cause of action of whatever nature which I, my heirs, executors, administrators, successors and assigns ever may have against any of them for, on account of, by reason of or arising in connection with my participation in Kohl's Step Up for Kids, and hereby waive any and all such claims, demand and causes of action. I also give full permission for use of my name and photograph in connection with this event.

Signature (guardian if under 18) Date


Please return completed and signed registration form with payment
(make checks payable to Children's Memorial Foundation) to:
Step Up For Kids
Children's Memorial Foundation
75 Remittance Drive, Suite 91287
Chicago, Illinois 60675-1287

© 2009 Children's Memorial Hospital. All rights reserved.