Event Purpose: To highlight the societal benefits of substance use disorder treatment/prevention, recognize the contributions of providers, and promote the message that recovery from substance use disorder in all its forms is possible. The event also encourages citizens to take action to help expand and improve the availability of effective substance use disorder treatment/prevention for those in need.

When: September 14, 2019, 8:00 a.m. – 12:00 p.m.
Place: Governors State University, One University Parkway, University Park, Illinois
Rain or shine – Program takes place indoors (walk is outdoors and is optional)


Master of Ceremony, Peter Palanca, Executive Vice President and COO, TASC, Inc.
Keynote Speaker:  TBD

8 a.m. - 12 p.m. Resource Fair
8-9 a.m. Walker Registration
9 - 10 a.m. Program
10-11 a.m. Campus Recovery Walk
11 a.m. Refreshments
11-noon Closing remarks

Full Name:


City/State/Zip Code:

Daytime Phone:

Phone Type:(cell/home/business):


Email address:

I am a(n): (alumni/student/friend):



Minor Child(ren) participating (name and age):


Governors State University (“GSU”) is committed to conducting academic, recreational and ancillary activities in the safest manner possible and holds the safety of participants in the highest possible regard. Participants and, if applicable, their parents and/or legal guardians must recognize, however, that there is an inherent risk of injury when choosing to participate in such activities, especially those that take place outside the school environment. GSU continually strives to reduce such risks and insists that all participants follow safety rules and instructions, which have been designed to protect the participant’s safety. Please recognize that GSU does not carry medical accident insurance for injuries sustained in its programs. Therefore, each person registering themselves or a minor child for a program or activity should review their own health insurance for coverage. It must be noted that the absence of health insurance coverage does not make Governor State University responsible for the payment of medical expenses. Please read this form carefully and be aware in signing and participating or permitting the participation of a minor child(ren) you will be waiving and releasing all claims for injuries you or the minor child(ren) might sustain arising out of this program. As a participant and/or parent or legal guardian of a participant in the Program, I recognize and acknowledge that there are certain risks of physical injury and I agree to assume the full risk of any injuries, damages or loss, which I and/or the minor child(ren) named below may sustain as a result of participating in any and all activities connected with or associated with such program. I am the parent or legal/guardian of the minor child(ren) named below. I grant permission of the minor child(ren) named below to participate in the Program. I UNDERSTAND THAT EACH MINOR CHILD PARTICIPATING IN THE ADDICTIONS STUDIES ALUMNI CLUB RECOVERY WALK MUST BE ACCOMPANIED BY ONE PARENT OR LEGAL GUARDIAN DURING THE ENTIRE EVENT. I agree to waive and relinquish all claims I or the minor child named below may have as a result of participating in the Program against Governors State University and its respective officers, agents, servants, volunteers and employees. I do hereby fully release and discharge Governors State University and its respective officers, agents, servants, volunteers and employees from any and all claims from injuries, damage or loss, which I may have or which may accrue to me on account of participation in the Program. I further agree to indemnify and hold harmless and defend Governors State University and its respective officers, agents, servants, volunteers and employees from any and all claims resulting from injuries, damages and losses sustained by me or the minor child(ren) named below arising out of, connected with or in any way associated with the activities of the Program. In the event of an emergency I authorized Governors State University officials to secure from any licensed hospital, physician and/or medical personnel any treatment deemed necessary for me or the minor child(ren) named below and agree that I will be responsible for payment of any and all medical services rendered.

I HEREBY CONSENT TO THE USE, PUBLICATION, BROADCAST, TELECAST, DISTRIBUTION AND CIRCULATION OF MY NAME, PHOTOGRAPH, IMAGE, AND/OR LIKENESS BY Governors State University (GSU) in any GSU-sponsored product and/or publication used for recruiting, promotional, advertising, or commercial purposes, and shall include, but not is limited to, the GSU website, newsletters, catalogs, trimester schedules, handbooks, and brochures. I further understand and agree that this picture release consent shall remain in full force and effect until canceled in writing and in reasonable advance of any said publication.


*By saying "yes" I Agree to Waiver: