RVHN Wellness Challenge

Registration

Name(Required)

First Last

Phone(Required)

Email(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Name 2

First Last

Phone 2

Email 2

Payment Options(Required)

Cash/Check

Online

Cash/Check Registration Fee

Price: $10.00

Payment is due before March 1.

Online Registration Fee

Price: $11.00

$1 covers processing fees.

Total

What community are you representing?(Required)

Appleton, MN

Dawson, MN

Madison, MN

Consent

I agree to the disclaimer listed below.

Fitness to Participate:
By choosing to participate, I am agreeing that I am medically able and properly trained. By participating, I warrant that I am in the physical condition necessary to complete the challenge; and have not been instructed not to do so by a health care professional.

Release of Liability for Negligence; Waiver Purpose and Scope of Agreement:
This agreement releases, discharges, and waives all ORDINARY NEGLIGENCE claims by you, or on your behalf; and is your agreement to assume all risk of injury, disability, or death due to ordinary negligence arising out of your participation in the RVHN Wellness Challenge. This waiver should be interpreted broadly, to the fullest extent allowable by the laws of the State of Minnesota. I hereby for myself, my spouse/partner, my heirs, executors, administrators or anyone else who might claim on my behalf, assume all risk of injury, disability or death and covenant not to sue, and waive, release, and discharge Chippewa, Lac qui Parle, or Swift Counties, the Cities of Appleton, Dawson, Madison, or Montevideo, Appleton Area Health, CCM Health, CCM Wellness Center, Johnson Memorial Health Services, Madison Health Care Services, and any organization associated with the race, including the local governments and police, volunteers, and any and all sponsors and the directors, officers, agents, employees, volunteers, assignees or anyone acting on their behalf, from any and all ordinary negligence claims or causes of action (known or unknown, foreseen or unforeseen) for death, personal injury or property damage of any kind or nature including those arising out of, their negligence, omission or carelessness in the course of, my participation in this other events and activities associated with this challenge. I understand that this release, hold harmless, and covenant not to sue is limited to claims for ordinary negligence and in no way shall be construed to release claims for conduct that constitutes greater than ordinary negligence, conduct that constitutes reckless or grossly negligent conduct or willful, wanton, or intentional acts.

Participation Agreement:
I further grant permission to Appleton Area Health, CCM Health, CCM Wellness Center, Johnson Memorial Health Services, and Madison Healthcare Services, and/or their agents authorized by them to use any photographs, videotapes, motion pictures, recordings, or any other record of this event for any purpose without limitation or compensation.