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The 4th Annual .5K Endurance Challenge

A run/walk to benefit

Ralston House

Saturday, August 14, 2010

Start Time: 10:00 a.m.

PARTICIPANT REGISTRATION FORM

Print and complete the form, enclose your check/payment information and send to:

Ralston House, 10795 W. 58th Avenue, Arvada, CO 80002

Payments also accepted at the cashier's office in the Arvada City Hall building at 8101 Ralston Rd.

Personal Information

Please indicate child or adult T-shirt size for each entrant: (6-8, 10-12, 14-16 for kids and S-XXL for adults)

Note: T-shirt size cannot be guaranteed if registered after 8/1/10.

First Name________________________ Last Name_____________________________ Shirt _________________

Additional members (for Fun 4 pack or Sponsor registration):

If form(s) are part of a sponsorship, name of sponsor___________________________________________________

First Name________________________ Last Name_____________________________ Shirt _________________

Mailing address __________________________________________________________________________

City_______________________________________________State________________ Zip _____________

E-mail address______________________________________

Daytime phone______________________________________

Total Enclosed

$______________

Payment Information

Postmarked Before 8/1/10 8/1/10 or After

Children (12 or under) $15 $20

Adult $20 $25

Fun 4 Pack $60 $70

(4 family members)

Team of 10 $120 $160

(10 team members)

attach additional forms

CANCELLATION: Entry fees are nonrefundable. Sorry, no exceptions. Race will be held rain or shine.

Make checks payable to: Ralston House

Credit cards: ___Visa ___MasterCard

Account #_________________________________________Exp. Date___________________

Name on card______________________________________________

Signature _________________________________________________

Acknowledgement of Risk, Release of Liability and Agreement.

By signing up for the race, you are agreeing to the release of liability.

1) I am registering for the .5K Endurance Challenge. I am fully aware this activity involves risks. I accept all the risks of participating, even if they are created by the negligence of the City of Arvada, Ralston House or its employees. "Risks" include physical exertion, crowds of people where a person may be hit or knocked down, authorized and unauthorized vehicles on the race course, and road and surface conditions. I know there are other risks that are not listed.

2) I fully release, discharge and waive any claims I may have, now or in the future, against the City of Arvada and Ralston House and its employees. "Claims" mean any liabilities, demands, legal actions and rights of action for damages, personal injury or death that are related to participation in the Fun Run Activities that I or my heirs or personal representative could make.

3) I am aware there is no obligation for any person to provide me with medical care during the .5K Endurance Challenge. If medical care is rendered to me, I consent to that care if I am unable to give my consent for any reason at the time that the care is rendered. I am aware it is advisable to consult a physician prior to participating in the race.

4) I agree not to consume alcoholic beverages before or during any of the .5K Endurance Challenge Activities.

5) I grant my permission to the City of Arvada and Ralston House to utilize any photographs, motion pictures, videotapes, recordings and any other references or records of the .5K Endurance Challenge Activities which may depict, record, or refer to me for any purpose, including commercial use.

6) I agree to abide by the rules of the .5K Endurance Challenge Activities. I am aware the rules prohibit bicycles or inline/roller skates. I acknowledge that, if I violate any of these prohibitions or other rules, I may be removed from the course.

7) If the participant is under 18 years of age, the parent or guardian agrees to the following statements: As a parent or guardian of the participant, I authorize the child to participate. I agree that in the event participant, or anyone acting on his or her behalf, should make any claims, I will provide the indemnity and hold harmless as described above.

FOR MORE INFORMATION, Call Ralston House at 720-898-6745 or EMAIL: dmoseley@arvada.org