AUTHORIZATION TO SUBMIT INFORMATION ON BEHALF OF A HOSPITAL ("SITE")


Please read the statements below in their entirety and indicate your agreement by checking the Yes/No boxes.
This is NOT a secure site.  You are submitting the required information voluntarily, not as an individual, but on behalf of a hospital (hereinafter "Site") interested in participating in Operation Walk USA 2019 (December 2-7, 2019).  You are an authorized representative and have the Site's permission to submit this information.

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* 1. I have read and agree with the statement above.

Operation Walk USA and its affiliates and agents respect your Site's privacy. 

By using this registration form, you - on behalf of your Site - agree to share with Operation Walk USA relevant and accurate information as identified on this form, and agree to the terms of Operation Walk USA's Privacy Policy.

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* 2. I have read and agree with the statement above.

Please allow 10-15 minutes to complete this questionnaire.  Only one (1) questionnaire per participating Site should be completed to avoid duplicate/conflicting records.  Please agree ahead of time who at your Site will be completing this questionnaire and submit as much information as currently available, understanding that some aspects of your participation might evolve.  At the same time, please be conservatively realistic in your estimates.

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* 3. By checking the box below, I certify that I am authorized by our Site to submit this information that is current and accurate to the best of my knowledge, information, and belief.

Please review the details of the 2019 General Participation Guidelines and share them with all relevant parties and stakeholders at your Site.

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* 4. By checking the box below, I certify that our Site has reviewed and is in agreement with the 2019 General Participation Guidelines, and will conduct Operation Walk USA 2019 branded activities according to these Guidelines.

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* 5. Who is completing this registration form?  (All fields must be filled.)

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* 6. Are you the primary contact with regard to your Site's participation in Operation Walk USA 2019?

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* 7. If answered "No" above, please provide the appropriate name/contact information:

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