Registration 100 Mile Challenge Registration Form April 4th – July 12th 2015 100 MILE CHALLENGE will officially begin April 4th. Late registrations will be accepted anytime during the challenge. However, T-shirts are only guaranteed to those who register by May 1st. Name* First Last Email* PhoneAddress* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Birth Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920AgePlease enter a value between 1 and 100.SexFemaleMaleSchool (if attending)Select T-Shirt Size*SmallMediumLargeX-LargeT-shirts are only guaranteed to those who register by May 15th.How did you hear about the 100 Mile Challenge?FlyerWebsiteWord of mouthAspen Medical CenterAspen WellnessRegistration & WaiverRegistration Fee*Adults - $20 Children under 17 - $10 Please select one belowAdultChild100 MILE CHALLENGE Consent, Waiver, Assumption of Risk Liability Release AgreementALL PARTICIPANTS MUST READ CAREFULLY AND SIGN THIS AGREEMENT. In consideration of the opportunity to participate and/or attend the 100 MILE CHALLENGE and its Events (including weekly group walks and party), the undersigned participant knowingly and voluntarily agrees to the following: I acknowledge that this is a walking and/or running event that involves physical activity and carries a potential for moderate and serious injury, death, property loss or damage. I understand the risks involved with attending the events that may include, but are not limited to: falls, slips, contact and/or crashes with other Participants, effects of weather including heat and/or humidity, cold, defective equipment, condition of the roads and/or course, rough terrain, water hazards, hazards posed by spectators or other Participants, man-made or natural obstacles, wild animals and poisonous plants. I ASSUME ALL RISKS INVOLVED WITH THE EVENTS and THE COURSES. I agree to monitor my health while participating in the Events, and will withdraw from the Events immediately and seek medical personnel if I believe continuing will present a risk to myself or other Participants. I agree that I will fully inspect the courses before participating, and notify the Events' personnel immediately of any hazardous situations. I agree to wear appropriate clothing and foot attire as established by industry standards and common safety practices during all activities at the Events. I acknowledge that I am not under the influence of alcohol, nor am I under the influence of any drugs, including prescription, illegal, or over-the counter medication, which could impair my ability to participate in the 100 MILE CHALLENGE. If I am taking medication, I affirm that I have seen a physician and have approval to participate in the 100 MILE CHALLENGE while under the influence of medication. I attest and verify that I am physically fit, have sufficiently trained for the Events, and that my physical condition has been verified acceptable to participate in the Events by a medical doctor prior to attending. I am covered by medical insurance, individually or as part of an organization. Further, I give my consent to medical treatment in the event of an emergency or other incident, in which, in the reasonable judgment of the on-site personnel, I require medical care. I assume all liability for any and all medical expenses incurred as a result of training for and/or attending the Events, including but not limited to: ambulance transport, hospital stays, physician and pharmaceutical goods and services. I agree, on my own behalf and on behalf of my heirs, estate, successors and assigns, to indemnify and hold harmless all Event organizers, landowners, producers, sponsors, advertisers, organizers, material suppliers, volunteers and/or contractors of any of the Events in which I may participate and/or attend, and all employees, principals, directors, shareholders, agents, members, managers, affiliates, representatives, attorneys and insurers of each of the foregoing (collectively, the “Released Parties”) against, any lawsuits, demands, claims, or expenses (including attorneys’ fees and legal costs), arising from or in any manner related to my attending the Events; and to the fullest extent permitted by law, I fully and forever waive, release, discharges and covenants not to sue Released Parties for and from any and all demands, claims, actions, suits, damages, losses, liabilities, costs and expenses arising, directly or indirectly, in related to, in connection with or relating to my participation or attending the Events from any cause whatsoever (including, but not limited to, damage or loss of property, bodily injuries, medical treatment and death), whether or not foreseeable or contributed to by the negligent acts or omissions of others. I acknowledge that the RELEASED PARTIES MAKE NO REPRESENTATION OR WARRANTY, EXPRESS OR IMPLIED, REGARDING THE EVENT and agree that the Released Parties will not, under any circumstance, be liable for consequential, indirect, general, special or similar damages. I acknowledge that this release and waiver of liability agreement will be used by the Released Parties and that it governs the legal rights and responsibilities of both me and the Released Parties. I understand that my entry fee is non-refundable under any circumstances. If any Event is canceled for any reason due to circumstances beyond reasonable control, the Event and/or Released Parties have no obligation to refund my entry fee or any other costs and/or expenses I incurred in connection with the Events. The Event organizers and Released Parties have the right to reject my entry for any reason. PHOTO RELEASE I hereby irrevocably release consent and allow the 100 MILE CHALLENGE and its agents to use my photograph, likeness, voice, asit pertains to my participation with the 100 MILE CHALLENGE events, in any manner for promotional efforts without expectation of any reimbursement for its use. This Waiver is a legally binding Agreement and will be construed broadly to provide a release and waiver to the maximum extent permissible under applicable law. Any provisions found to be void or unenforceable shall be severed from this agreement, and not affect the validity or enforceability of any other provisions. I have read this document and I fully understand its content, warning of risk, assumption of risk and waiver and release of all claims. I understand that by signing below, I have given up substantial rights. I have voluntarily signed this release. By signing below, you agree, warrant and covenant as follows I HEREBY AFFIRM THAT I AM EIGHTEEN (18) YEARS OF AGE OR OLDER. I HAVE READ THIS DOCUMENT AND UNDERSTAND ITS CONTENTS. IF THE Participant IS UNDER EIGHTEEN (18) YEARS OF AGE, A PARENT OR LEGAL GUARDIAN MUST SIGN BELOW. Participant’s Parent or Guardian’s signature above certifies that Participant’s son/daughter/ward has permission to participate/attend the 100 MILE CHALLENGE Events. Participant’s Parent/Guardian has read and understands the foregoing WAIVER AND RELEASE AGREEMENT (above) and by signing intentionally and voluntarily agrees to its terms and conditions. Participant’s Parent/Guardian further certifies that such son/daughter/ward is in good physical condition and is able to safely participate in the Events. Participant’s Parent/Guardian hereby authorizes medical treatment for such son/daughter and grants access to such child’s medical records as necessary and as stated above. I have read and agree to the terms above.*YESSignature*By signing you agree to the terms and conditions above.PaymentTotal $0.00 Credit Card* American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20192020202120222023202420252026202720282029203020312032203320342035203620372038 Expiration Date Security Code Cardholder Name CommentsThis field is for validation purposes and should be left unchanged.