FireWalk Registration

This form must be signed in order to engage in the Fire Walk.  The registrant will also need to sign the legal Release Form, in order to actually participate in the event.  The participant understands and has been notified that walking on fire is a potentially dangerous activity and, even though walking on fire is not required, the participant will be around fire and extremely hot temperatures. In addition the participant is being asked to support other people who may choose to walk on the fire.

This Form cannot be submitted until the missing fields (labelled below in red) have been filled in
FireWalk Registration Form
Please note that all fields followed by an asterisk must be filled in.
Date of FireWak*	---Select---May 4, 2013
First Name*
Last Name*
E-Mail Address*
Street Address*
City*
State/Prov*
Zip/Postal Code*
Home Phone
Business Phone
Mobile Phone
Best Number to Contact You*
Participant’s parent or guardian (Required if under the age of 19)
A brief statement of what you want to get out of this FireWalk.*
Please enter the word that you see below.