ACHD Suicide Prevention & Memorial Walk – Registration Form

Sunday, September 14, 2025 | 1:00 PM – 3:00 PM | Rocky Gap State Park

PARTICIPANT INFORMATION

Full Name:

Age:

Phone Number:

Email Address:

Address:

PARTICIPATION DETAILS

1. How are you participating today?

Walking in memory of someone Walking in honor of someone Walking to support the cause Volunteering Other:

2. Are you attending with a group or team?

Yes No

OPTIONAL INFO FOR EVENT PLANNING

3. Would you like to receive future updates or mental health resources?

Yes, via email Yes, by mail No, thank you

EMERGENCY CONTACT

Name:

Phone Number:

SIGNATURE & CONSENT

By signing, I acknowledge that I am participating voluntarily and understand this event may involve physical activity. I grant permission for photos taken at the event to be used in promotional materials unless I opt out by notifying event staff.

Signature:

Date:

I consent to this website collecting my personal data via this form.

I hereby declare myself to be physically sound and suffering from no condition, impairment, disease, or other illness which would prevent my participation in the Suicide Prevention & Memorial Walk

By attending this event, you agree to abide by all rules and regulations set forth by the state park.

12501 Willowbrook Rd SE, Cumberland, MD 21502 / 301-759-5070

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ACHD Suicide Prevention & Memorial Walk – Registration Form

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