Offline Midwest Monster Adventure Challenge Entry Form

2007 Midwest Monster Adventure Challenge Offline Registration

Please type in the your team's information. Print and mail registration form when finished.

(Use the 'Tab' key to advance to the next field.)

Team Name:

Captain's Name:

Street Address:

City: State:

Zip:

Daytime Phone:
Shirt Size:

Email:

Emergency Contact:

Emergency Phone:

Age:

DOB (mm/dd/yy):

Skill Level:

USARA#:

Long Course Short Course

Member #2:

Street Address:

City: State:

Zip:

Daytime Phone:

Shirt Size:

Email:

Emergency Contact:

Emergency Phone:

Age:

DOB (mm/dd/yy):

Gender:

Skill Level:

USARA#:

Member #3:

Street Address:

City: State:

Zip:

Daytime Phone:

Shirt Size:

Email:

Emergency Contact:

Emergency Phone:

Age:

DOB (mm/dd/yy):

Gender:

Skill Level:

USARA#:

Member #4:

Street Address:

City: State:

Zip

Daytime Phone:

Shirt Size:

Email:

Emergency Contact:

Emergency Phone:

Age:

DOB (mm/dd/yy):

Gender:

Skill Level:

USARA#:

How did you hear about the Monster Adventure Challenge?

Method of Payment? Check Credit Card

The entry fee is $90 per person plus $8 per person for insurance ($98).(USARA members are exempt from the insurance fee if you give your membership number above.) The entry fee must be recieved by before raceday. Please make checks payable to " Quincy Regional Crime Stoppers". Please mail this form, your check, and the signed Personal Injury Disclaimer and Medical Insurance Waiver form to the address below, or call (217) 222-7055 if paying with a major credit card. The entry fee is non-refundable and the race will not be cancelled due to inclement weather. Your team's registration will not be processed without full payment. Confirmations will only be emailed to your team's captain. You can also fax entry form to 217-222-7056.

Quincy Regional Crime Stoppers
c/o Mike Predmore
P.O. Box 56
Quincy, Illinois 62305

Personal Injury Disclaimer

Incomplete or unsigned entries will not be accepted

I know that competing in an adventure race is a potentially hazardous activity. I should not enter and compete unless I am medically able and properly trained. I agree to abide by any decision of a race official relative to my ability to safely complete the race. I assume all risks associated with adventure racing including, but not limited to, falls, contact with other participants, the effects of the weather, including high heat and/or humidity, obstacles, special tests, hypothermia, dehydration, wildlife, water craft or other vehicles, drowning, the condition of the course and traffic on the course, all such risks being known and appreciated by me. Having read this waiver and knowing these facts, and in consideration of your acceptance of my application, I, for myself and anyone entitled to act on my behalf, waive and release the Midwest Monster Adventure Challenge, NFP, its officers, directors and agents; The City of Quincy, Illinois; Adams County, Illinois; Columbus Township; Riverside Township; the Illinois Department of Natural Resources; and all race sponsors, their representatives and successors, from all claims or liabilities of any kind arising out of my participation in this activity even though that liability may arise out of negligence or carelessness on the part of the persons or entities named in this waiver.

Medical Insurance Waiver

The undersigned hereby acknowledges that the Midwest Monster Adventure Challenge (nfp) strongly urges all race participants to obtain health insurance coverage prior to participation in the race. In consideration of being allowed to participate in any way in the Midwest Monster Adventure Challenge, the undersigned shall assume all risk of injury, disclosed and not disclosed and known and unknown as well as the responsibility of paying for any and all medical care or treatment that may become necessary as a result of any injury suffered by the undersigned during the Midwest Monster Adventure Challenge or any other pre-race or post-race activity conducted by the Midwest Monster Adventure Challenge(nfp). The undersigned hereby agrees that he/she shall fully indemnify the Midwest Monster Adventure Challenge(nfp) for any and all costs of medical care received or to be received by the undersigned as a result of any such injuries

Print Name ______________________ Signature __________________________ Date_____________

Please mail this signed Personal Injury Disclaimer and Medical Waiver form along with your payment to the address above. This form must be signed by all teammates in order for your team to compete in the Midwest Monster Adventure Challenge.