150 Minute Challenge

Hope Village 150 Minute Challenge
Hope Village residents, please fill in the form below to register for the Hope Village "150 Minute Challenge"
Participant Information
First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number*

Area CodePhone Number
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Person*

First NameLast Name
Emergency Person Phone Number*

Area CodePhone Number
Relationship to Emergency Contact Person*
What are your wellness goals?
How do you like to be supported?
What are your favorite physical activities?

WalkingGardeningDancePlaying BasketballBaseballBoxingSwimmingSkatingOther
Do you prefer to exercise alone or with others?
Are you willing to track and report your physical activity to HOPE Village Revitalization?
Do you prefer to be contacted by phone/text/email?
Release & Agreement
I wish to participate in the "150 Minute Challenge" led by Hope Village Revitalization. I understand that physical activity involves physical exercise and movement, and that surfaces are not always completely flat. As with any physical activity, the risk of injury is always present and cannot be entirely eliminated. If I experience any pain or discomfort, I will listen to my body, discontinue the activity, and ask for support. I understand that it is recommended that each participant consult with their own physician before participating in the "150 Minute Challenge".

In signing this release and waiver of liability, I acknowledge and understand its intent and I, for myself, my heirs, executors, administrators and representatives, do hereby agree and will absolve and hold harmless HOPE Village Revitalization, a Michigan non-profit corporation and its directors, officers, employees and agents. I (hereinafter “Participant”) hereby freely, voluntarily and without duress execute this Release and Waiver under the following terms:

1. Waiver and Release. Participant hereby releases and forever discharges and holds harmless HOPE Village Revitalization and its successors and assigns from any and all liability, claims and demands of whatever kind or nature, either in law or in equity, which arise or may hereafter arise from Participant's participation. Participant understands that this Release discharges HOPE Village Revitalization from any liability or claim that the Participant may have against HOPE Village Revitalization with respect to any bodily injury, personal injury, illness, death or property damages that may result from Participant's participation, whether caused by the negligence of HOPE Village Revitalization or its officers, directors, employees or agents or otherwise. Participant also understands that HOPE Village Revitalization does not assume any responsibility for or obligation to provide financial assistance or other assistance, including but not limited to, medical, health or disability insurance.

2. Medical Treatment. Participant hereby releases and forever discharges HOPE Village Revitalization from any claim whatsoever which arises or may hereafter arise on account of any first aid, treatment or service rendered in connection with the Participant's involvement in these activities.

3. Insurance. HOPE Village Revitalization does not carry or maintain, and expressly disclaims responsibility for providing any health, medical or disability insurance coverage for the Participant. EACH PARTICIPANT IS EXPECTED AND ENCOURAGED TO ARRIVE WITH MEDICAL OR HEALTH INSURANCE COVERAGE IN EFFECT.

4. Other. Participant expressly agrees that this Release is intended to be as broad and inclusive as permitted by the laws of the State of Michigan, and that this Release shall be governed by and interpreted in accordance with the law of the State of Michigan. Participant agrees that in the event that any clause or provision of this Release shall be held to be invalid by any court of competent jurisdiction, the validity of such clause or provision of this Release which shall continue to be enforceable.

5. I grant HOPE Village Revitalization, its representative and employees the rights to take photographs of me in connection with the event/subject listed above. I authorize and agree that HOPE Village Revitalization may use photograph or video of me with or without my name and for any lawful purpose including publicity, illustration, web content and promotional uses.
Signature*

Clear
Date Signed*

MonthDayYear
Date
Should be Empty:

Hope Village 150 Minute Challenge

Participant Information

Release & Agreement