The 5th Annual .5K Endurance Challenge
Three run/walks to benefit
Ralston House
PARTICIPANT REGISTRATION FORM
----ONE FORM PER PERSON----
Print and fill out this form.
Read and sign your agreement to the Waiver and Release of Liability.
Enclose your check/payment information and send to:
Ralston House, 10795 W. 58th Avenue, Arvada, CO 80002
Print Pledge Forms (optional) to collect pledges for Ralston House.
Send completed Pledge Form(s) and money collected to Ralston House or bring to race.
Personal Information
Please indicate child or adult T-shirt size: Child S (6-8), Child M (10-12), Child L (14-16)
Adult S, M, L, XL, XXL
Note: T-shirt size cannot be guaranteed if registered close to race day.
ONE FORM PER PERSON
(multiple forms can be submitted together and paid by one person)
First Name______________________ Last Name__________________________ Shirt Size _________
If part of a sponsorship, name of sponsor___________________________________________________
Team/Family Name, if applicable__________________________________________________________
Mailing address ______________________________________________________________________
City_______________________________________________State____________ Zip _____________
E-mail address______________________________________ Daytime phone_____________________
Payment Information
Costs are shown before and after race day
Costs are shown before and after race day OVER Arvada Race - June 11 _____Golden Race - June 18
_____Golden Race - June 18_____Lakewood Race - July 9 _____All 3 Races - I want to TRI-umph!!
_____All 3 Races - I want to TRI-umph!! One RaceTwo RacesAll Three RacesChildren (12 or under) $15 / $20$30 / $40 $35 / $50
$30 / $40 $35 / $50 Seniors (62 or over) $15 / $20$30 / $40 $35 / $50
$15 / $20$30 / $40 $35 / $50Adult $20 / $25$40 / $50 $50 / $65
$20 / $25$40 / $50 $50 / $65 Fun 4 Pack $60 / $70 $120 / $140 $150 / $200
$60 / $70 $120 / $140 $150 / $200(4 family members)
Team of 10 $120 / $160 $240 / $300 $300 / $350
$120 / $160 $240 / $300 $300 / $350 (10 team members)
Total Enclosed$______________
$______________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 ______________________________
.5K WAIVER AND RELEASE OF LIABILITY
In consideration of my being allowed to participate in the Ralston House .5K Endurance Challenge, I agree that I will not hold Ralston House, the City of Arvada, or any of their officers, employees, or agents ("Organizers") responsible for any injuries or losses I might incur while participating in the .5K. I am aware that this activity involves risks, including but not limited to: the dangers of colliding with fixed or moving people or objects, the dangers of surface hazards, inadequate safety or other equipment, or adverse weather conditions, and the risks inherent in any athletic activity or competition.
For myself, my heirs, executors, administrators, legal representatives, assignees, and successors in interest, I hereby release the Organizers from any and all claims, liabilities, demands, damages, lawsuits, and other causes of action arising from my participation in the .5K, even those arising from the negligence of the Organizers. I also agree to indemnify the Organizers for any damage or harm I may cause another based on my participation in the .5K.
I have consulted with my health care provider and represent that I am fit to participate in the .5K Endurance Challenge. In the event of an illness, injury, or medical emergency, I authorize the Organizers to provide or secure any treatment or transport deemed reasonably necessary for my immediate care. Furthermore, I agree that I will be responsible for the costs of any and all such care and transport.
I grant the Organizers permission to use my photograph, picture, likeness, or voice in any media format whatsoever, and for any purpose whatsoever, including commercial advertising, and waive any compensation for such use. I agree to abide by all rules of the .5K, and understand I may be removed from the course for violation of the rules.
If I am signing this WAIVER AND RELEASE OF LIABILITY on behalf of my child or ward, I authorize my child or ward to participate in the .5K, and make the representations contained herein on behalf of my child or ward. I also agree to indemnify for and release liability on behalf of my child or ward as set forth herein.
This WAIVER AND RELEASE OF LIABILITY may not be modified orally. Terms of this WAIVER AND RELEASE OF LIABILITY are severable; if any one or more of them is found to be unenforceable or invalid by a court of competent jurisdiction, that shall not affect the other terms, which shall remain binding and enforceable. Representations I have made in this WAIVER AND RELEASE OF LIABILITY are contractually binding on me, my heirs, executors, administrators, legal representatives, assignees, and successors in interest. I understand that the Organizers are relying on the representations made herein.
Print name: ___________________________________________________
Signature:_____________________________________________________
Date:______________________
Parent Signature (if entrant is under 18):____________________________
Date:_________________________
FOR MORE INFORMATION, Call Ralston House at 720-898-6745 or EMAIL: dmoseley@arvada.org
