Operation Walk USA 2023 Participating Hospital ("Site'") Registration for December 4-9, 2023

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 2023. You are an authorized representative and have the Site's permission to submit this information.

Question Title

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

Yes

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.

Question Title

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

Yes

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.

Question Title

* 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.

Yes

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

Question Title

* 4. By checking the box below, I certify that our Site is reviewing/has reviewed and is in agreement with the General Participation Guidelines, and will conduct Operation Walk USA 2023 branded activities according to these Guidelines.

Yes

Question Title

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

Name *

Company *

Address *

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

Email Address *

Phone Number *

Question Title

* 6. Are you the primary contact with regard to your Site's participation in Operation Walk USA 2023?

Yes

Question Title

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

Full name:

Title:

Email:

Phone:

Extension: