Suicide Prevention Across Rush County

Suicide Prevention Across Rush County (SPARC) is a community task group dedicated to suicide prevention and awareness activities in Rush County.

Our goals and activities include:

Raising suicide awareness and reduce stigma through community events and education
Transforming suicide care provided in our community with an emphasis on improving accessibility and effectiveness
Coordinating community training on suicide and other mental health needs
Supporting SPARC Youth Voice, a group of local youth that meets regularly to raise suicide awareness, learn about mental health, and connect to mental health resources in the community

The SPARC Fund is a part of the Healthy Community Funds of the Rush Memorial Hospital Foundation.

SPARC Suicide Prevention Walk Registration

After filling out this form, PLEASE download and fill out this release form for the event. Forms can be emailed, mailed, or hand-delivered.

Each form submission is for one person. If you are attending in a group, each individual participant will need to fill out their own form.

SPARC Registration

Step 1 of 2

50%

Name(Required)

First Last

I would like to participate in:(Required)

SPARC Event without T-Shirt - $0

Hidden

I would like to participate in:(Required)

Note: Deadline for t-shirts is Aug. 22, 2023

SPARC Event without T-shirt – $0

SPARC Event with T-shirt – $20

SPARC T-Shirt ONLY – $20

Shirt Size(Required)

Please Check One

Youth Small

Youth Medium

Youth Large

Youth XL

Adult Small

Adult Medium

Adult Large

Adult XL

Adult 2XL

Adult 3XL

Adult 4XL

Adult 5XL

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone(Required)

Email(Required)

Age(Required)

Gender(Required)

Male

Female

Other

I do not wish to disclose my gender.

Gender:

Additional Donation:

$25

$50

$75

$100

Other

Other Donation Amount:

Consent(Required)

I am aware that any photographs taken during the event may be used in future publications and I grant the Hospital and the Foundation all rights to use these photographs in any medium for educational, promotional advertising, or other purposes that support the mission of the Hospital and the Foundation.

I agree

Signature(Required)

Date(Required)

Total

Credit Card

American Express

Discover

MasterCard

Visa

Supported Credit Cards: American Express, Discover, MasterCard, Visa

Card Number

Expiration Date Month Year

Security Code Cardholder Name

RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK, INDEMNITY AND PARENTAL CONSENT AGREEMENT

Agreement(Required)

IN CONSIDERATION of being permitted to participate in any way in any Rush Memorial Hospital Foundation or Rush Memorial
Hospital event ("Activity") I, for myself, my personal representative, assigns, heirs, and next of kin:
1. ACKNOWLEDGE, agree and represent that I understand the nature of sports activities and that I am qualified, in good health and in
proper physical condition to participate in such activity. I further agree and warrant that if at any time I believe conditions to be
unsafe, I will immediately discontinue further participation in the activity.
2. FULLY UNDERSTAND that: (a) SPORTS ACTIVITIES INVOLVE RISKS AND DANGERS OF SERIOUS BODILY lNJURY,
INCLUDING PERMANENT DISABILITY, PARALYSIS, AND DEATH ("RISKS"); (b) these Risks and dangers may be caused
by my own actions or in-actions, the actions or in-actions of others pa1ticipating in the activity, the conditions in which the activity
takes place, or THE NEGLIGENCE OF THE "RELEASEES" NAMED BELOW; (c) there may be OTHER RISKS AND SOCIAL
AND ECONOMIC LOSSES either not known to me or not readily foreseeable at this time; and I FULLY ACCEPT AND ASSUME
ALL SUCH RISKS AND ALL RESPONSlBILlTY FOR LOSSES, COSTS, AND DAMAGES I incur as a result of my participation
or that of the minor in the activity.
3. HEREBY RELEASE, DISCHARGE, AND COVENANT NOT TO SUE Rush Memorial Hospital or the Rush Memorial Hospital
Foundation, their administrators, directors, agents, officers, members, volunteers, other participants, sponsors, advertisers, and if
applicable, owners and lessors of premises on which the activity takes place, (each considered one of the "RELEASEES" herein)
FROM ALL LIABILITY, CLAIMS, DEMANDS, LOSSES, OR DAMAGES ON MY ACCOUNT CAUSED OR ALLEGED TO
BE CAUSED IN WHOLE OR IN PART BY THE NEGLIGENCE OF THE "RELEASEES" OR OTHER WISE, INCLUDING
NEGLIGENT RESCUE OPERATIONS; AND I FURTHER AGREE that if, despite this RELEASE AND WAIVER OF the
"RELEASEES", I WILL INDEMNIFY, SAVE, AND HOLD HARMLESS EACH OF THE RELEASEES from any litigation
expense, attorney fees, loss, liability, damage, or cost which any may incur as the result of such claim.
l HAVE READ THIS AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HA VE GIVEN UP
SUBSTANTIAL RIGHTS BY SIGNING IT AND HAVE SIGNED IT FREELY AND WITHOUT ANY INDUCEMENT OR
ASSURANCE OF ANY NATURE AND INTEND TO BE A COMPLETE AND UNCONDITIONAL RELEASE OF ALL
LlABILlTY TO THE GREATEST EXTENT ALLOWED BY LAW AND AGREE THAT IF ANY PORTON OF THIS AGREEMENT
IS HELD TO BE INVALID THE BALANCE, NOTWITHSTANDING, SHALL CONTINUE IN FULL FORCE AND EFFECT.

I agree to and accept these terms

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone(Required)

Printed Name(Required)

First Last

Signature(Required)

Date(Required)

MM slash DD slash YYYY

Minor Release(Required)

AND I, THE MINOR'S PARENT AND/ OR LEGAL GUARDIAN, UNDERSTAND THE NATURE OF SPORTS ACTIVITIES AND
THE MINOR'S EXPERIENCE AND CAPABILITIES AND BELIEVE THE MINOR TO BE QUALIFIED, IN GOOD HEALTH, AND
IN PROPER CONDITION TO PARTICIPATE IN SUCH ACTIVITY. I HEREBY RELEASE, DISCHARGE, COVENANT NOT TO
SUE, AND AGREE TO ANDEMNIFY AND SAVE AND HOLD HARMLESS EACH OF THE RELEASEE'S FROM ALL
LIABILITY, CLAIMS, DEMANDS, LOSSES, OR DAMAGES ON THE MINOR'S ACCOUNT CAUSED OR ALLEGED TO BE
CAUSED IN WHOLE OR IN PART BY THE NEGLIGENCE OF THE "RELEASEES' OR OTHERWISE, INCLUDING NEGLIGENT
RESCUE OPERATIONS AND FUTHER AGREE THAT IF, DESPITE THIS RELEASE, I, THE MINOR, OR ANYONE ON THE
MINOR'S BEHALF MAKES A CLAIM AGAINST ANY OF THE RELEASEES NAMED ABOVE, I WILL INDEMNIFY, SAVE,
AND HOLD HARMLESS EACH OF THE RELEASEES FROM ANY LITIGATION EXPENSES, ATTORNEY FEES, LOSS
LIABILITY, DAMAGE, OR COST ANY MY INCUR AS THE RESULT OF ANY SUCH CLAIM.

I agree to and accept these terms

Phone(Required)

Printed Name of Parent/Guardian(Required)

First Last

Signature of Parent/Guardian(Required)

Date(Required)

MM slash DD slash YYYY

SPARC Suicide Prevention Walk Registration

SPARC Registration

RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK, INDEMNITY AND PARENTAL CONSENT AGREEMENT

Bella & Beaus 2024

April 19, 2024