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World AIDS Day Event Logo

Please complete this form by November 27, 2023

During our "Say My Name" candlelight vigil and on our "Wall of Rememberance" display, we will be reading names and displaying photos to remember those who have passed away due to HIV/AIDS. If you would like to honor an immediate family member or public figure, please provide their name and/or picture below. If you are honoring someone who is not an immediate family member or a public figure, please complete the written permission form and upload the document below.

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Written Permission Form


I wish to participate in the Care 4 U Community Health Center's 3rd Annual Bike Ride in observance of World AIDS Day on December 1, 2023. In signing this release, I acknowledge that I understand its intent, and I for myself, my heirs, executors, administrators and representatives, do hereby agree and will absolve and hold harmless the Care 4 U Community Health Center, their employees, agents, cooperating organizations and any other parties connected with this event in anyway together with their respective successors and the Sponsors singularly and collectively, from and against any blame and liability for any injury, harm, loss, inconvenience or any other damage of any kind whatsoever, which may result from or be connected in any way to my participation in the Inaugural Bike Ride.


I understand there are risks inherent with bike riding on public streets and highways where many hazards exist. I am voluntarily participating in this event with knowledge of the all the hazards involved and accept all risks of injury, inconvenience, harm, loss or death.


I am physically capable of participating in the event and the equipment I will use will be in proper working condition. I acknowledge that I, and I alone, am solely responsible for my personal health and safety, and the personal property I bring with me. I agree to wear a helmet, adhere to all other event rules, all traffic rules and laws, and conduct myself in a safe and prudent manner while participating in the event.


I give the Care U Community Health Center and other cooperating organizations permission to use my name and any photograph, voice or likeness of me or my during the event in any promotional materials or publications. I consent to and authorize in advance such use and waive my rights of privacy in connection therewith.

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