4167 Rappahannock Avenue, San Diego, California 92117 manager@ccsasandiego.org 858-274-2273

Consent Form

Statement of Consent

I understand the risks involved in participating in the Community Christian Service Agency (CCSA) Hunger Walk and willingly and voluntarily accept these risks.  I attest that I am physically fit and prepared for this event.

I grant permission for the organization to use photographs/images and quotations from me in accounts and promotions of this event.

Name of Walker (PRINT) ___________________________________Date __________________

Signature: _________________________________

If walker is under 18, parent or guardian signature is required here.

Organization: ______________________________

The information below will be used only to contact you about future CCSA events.

Address________________________________City______________________Zip______________

Phone ________________________________

Email ______________________________________

Are you willing to receive the CCSA newsletter by e-mail?  _____ Yes    _____No