10-Week Health & Wellness Fitness CHALLENGE REGISTRATION FORM
Date: March 15, 2025 - May 30, 2025 Anytown, USA
Choose One:
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TEAM CAPTAIN
TEAM Participant
TEAM NAME [ask your Team Captain (if unknown)] If you are the Team Captain, please write-in your team name
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Name
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First Name
Middle Name
Last Name
Address:
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
E-mail
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example@example.com
Contact Number
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Sex
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Please Select
Male
Female
N/A
Age on Event Date
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In Case of Emergency
Emergency Contact:
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First Name
Last Name
Relationship
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Contact Number
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Release and Waiver of Liability - Assumption of Risk and Indemnity Agreement
In consideration of my participation in the10-Week Health & Wellness Fitness Challenge, I, the undersigned participant, hereby acknowledge and agree to the following:
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I am fully aware of the risks involved in participating in a 10-Week Health & Wellness Fitness CHALLENGE and voluntarily assume all such risks.
I am physically fit and have no medical conditions that would prevent my participation in the 10-Week Health & Wellness Fitness CHALLENGE.
I agree to comply with all rules and regulations of the 10-Week Health & Wellness Fitness CHALLENGE.
I release, discharge, and hold harmless the organizers of the 10-Week Health & Wellness Fitness CHALLENGE, their officers, directors, employees, volunteers, sponsors, and any other persons or organizations associated with the10-Week Health & Wellness Fitness CHALLENGE from any and all claims, damages, or injuries, including death, that may arise from my participation in the 10-Week Health & Wellness Fitness CHALLENGE or as a result of my use of any facilities or equipment provided by the 10-Week Health & Wellness Fitness CHALLENGE.
I agree to take part in DTD's Juneteenth 5K Walk/Run Event on June 7, 2025. The cost is $25.00 per person (team member).
I agree to take part in FREE 10-Week Health & Wellness Fitness CHALLENGE that requires a structured 30-min walk per week for 10-weeks where the schedule is determined by my Team Captain.
I can opt out of participation of the 10-Week Health & Wellness Fitness CHALLENGE no later than March 31, 2025.
Date
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Month
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Day
Year
Date
Signature
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