5 K Start Time: 9:00 Am Kids K Start Time: 10:00 Am

Chamber Challenge 5K, & Kids K

April 9, 2016

5 K start time: 9:00 am Kids K start time: 10:00 am

ADDRESS:

CITY: STATE: ZIP:

PHONE NUMBER: E-MAIL ADDRESS GENDER (M or F)

Age as of April 9, 2016:

Circle Shirt Size: Youth : S M L Adult: S M L XL 2XL

Circle Event: 5K: $25.00 Kids K: $10.00 (for first child, $5.00 each additional child)

Make Checks Payable to: Missouri Valley Chamber of Commerce

Mail Registration to:

Missouri Valley Chamber of Commerce 100 S 4th Street Missouri Valley, IA 51555 RELEASE OF LIABILITY

I know that running/walking in a road race is potentially hazardous activity. I represent that I am medically able and properly trained to participate in this event. I assume all risks associated with this event including, but not limited to, heat exhaustion, falls, contact with other participants, effects of weather, dangerous traffic conditions, etc, all such risks being known and recognized by me. I hereby agree, for myself and my heirs, assigns, personal representative, executors and administrators, to waive, release, and forever discharge the Missouri Valley Chamber of Commerce and its respective directors, officers and employees, volunteers, and any and all sponsors, suppliers and any other personnel assisting or connected with this event, any rights, claims, or demands therefore which I may have or which I may hereafter accrue to me arising out of injury to my person or my property incurred in connection with participation in the Chamber Challenge 5K, and Kids K Challenge held on April 9, 2016.

Signature: Date

Parent Signature (if under 19 years of age)