Registration

The first step to register for the '2010 1000 Mile Walk' event is to have one member of your team (the team leader) register your new team by filling out the simple form below. Once you register your team - you will be directed to the 'Miles Walked' page. This page will serve as your main login page moving forward. There you will be able to add individual team members and post miles walked throughout this event.

Thanks for entering!

	Create your own username and password
Username:
Password:
Password (confirm):

Team Name:
First Name:
Last Name:
Address - Line 1:
Address - Line 2:
City:
State:
Zip Code:
Phone (daytime):
Phone (evening):
Email:
Source of information:
Gender:	Female Male
Age bracket:	10-18 18-29 30-49 50-69 70-99
Affiliation:

Waiver Statement for General (Non-Company Affiliated) Participants
All participants must sign the Waiver Statement before participating in the program. The Team Leader should download the Waiver Statement here, make copies for each Team Member, have them read and sign the form, and return the signed Statement to Dr. K Chris Chung at chrischung1000@gmail.com.

If you have any questions, please e-mail Dr. K Chris Chung at chrischung1000@gmail.com. Thank you.

I have read and understand the Waiver Statement.

Waiver Statement for Company Affiliated Participants
All the employees of the PHP hospitals, Atrium Medical Center, Good Samaritan Hospital and Miami Valley Hospital, must sign the Waiver Statement before participating in the program. The Team Leader should download the Waiver Statement here, make copies for each Team Member, have them read and sign the form, and return the signed Waiver Statement to the officer of the appropriate hospitals. The Officers' names and offices are listed below.

Atrium Medical Center: Yonathan Kebede ext. 6879, Fax: 513-420-5657

Good Samaritan Hospital: Alice Riancho ext. 5701

Miami Valley Hospital: Joy Egler ext. 3899

PHP Corporate Services: Denise Vanderhorst ext. 5427, Fax: 937-223-9866

If you have any questions, please direct your inquiry to the above officers or e-mail Dr. K Chris Chung at chrischung1000@gmail.com. Thank you.

I have read and understand the Waiver Statement.