Chewelah Chataqua Challenge
Saturday, July 9th, 2005
Name: ________________________________ Phone: ___________________
Address: _____________________________ Birthdate: _________________
City: ____________________________ State: __________ Zip ____________
Shirt Size: (Circle One) Adults: S M L XL XXL No Shirt
Age Group: (Circle One) 0-13 14-19 20-29 30-39 40-49 50-59 60+
Gender: (Circle One) male female
Race Course: (Circle One) 5K 10K
Declaration:
In consideration of acceptance of this entry and intending to be legally bound, I hereby release all claims which may arise on my behalf against the Chewelah Chataqua Challenge, Community Celebrations, City of Chewelah, or any sponsors of this run or their officers, agents, representatives, or volunteers for any and all losses or injuries which I may sustain due to the participation in or traveling and from the Chewelah Chataqua Challenge. I have full knowledge of the risks involved in the race and will assume them. I know that vehicles will be on the course. I will not use a walker or other similar device during the race. I will assume and pay my own expenses in the event of any incapacity regardless whether I have authorized such expenses. I attest that I am physically fit to participate in the race. I have read the above statement and my signature confirms it’s full acceptance.
Entry Not Valid Without Signature
Runner Signature: ___________________________________ Date: ____________
Parent/Guardian Signature if runner is under 18 _______________________________
Mail to:
Chataqua Challenge, P.O. Box 105, Chewelah, WA 99109