UTIA Family, please refer utk.edu/coronavirus for the latest updates and student information. For UTIA-specific resources, please visit utia.tennessee.edu/coronavirus .

WAT Individual Registration Form

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UT Extension-Dickson County
204 Henslee Drive
Dickson, TN 37055

If you have questions or concerns, please contact email:
Janet Cluck @ jccluck@utk.edu

WALK ACROSS TENNESSEE 

WAT Guy logo

Dickson County

Each individual walker is required to complete this form.

Individual Registration Form

WAT Individual Registration
First
Last
Mailing Address
Mailing Address
City
State/Province
Zip/Postal
Enter Email
Confirm Email
Gender:
MY personal goals for walking/running include:(check all that apply)

Section

Waiver

I wish to participate voluntarily in the Walk Across Tennessee physical activity for the purpose of personal fitness. I understand that I should have medical approval from my health care professional if I:

have any chronic health problems such as heart disease or diabetes.
have pains in my heart/and or chest areas.
feel dizzy or have spells of severe dizziness.
have a bone or joint condition, like arthritis, that might be made worse by an exercise program.
have been told by a doctor that I have high blood pressure.
have any physical conditions or problems that might require special attention in an exercise program.
am a male over 45 or female over 50 and not accustomed to vigorous exercise.

Participants under age 21 must also have parent or guardian approval.

I agree to this waiver and agree to accept full responsibility for any injuries I may sustain while participating in this program and hold harmless all Sponsoring Parties.

Parent or Guardian of Walker:
University of Tennessee Extension offers its programs to all eligible persons regardless of race, religion, color, national origin, sex, age, disability, or veteran status.
I agree to this waiver and agree to accept full responsibility for any injuries I may sustain while participating in this program and hold harmless all Sponsoring Parties.