Creating Wellness Frederick, LLC

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Thank you for your interest in registering for the Frederick Wellness Challenge! Please fill out the form below. Your place will be reserved once we have received your payment.

Account information

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E-mail address: *

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Registration Information

First Name: *

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Last Name: *

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Home Phone: *

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Cell Phone: *

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Occupation: *

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Birthdate: *

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Mailing Address: *

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Refered by:

Please place the name of the individual who refered you to the challenge here.

Team Request:

If there is a specific team you would like to join, or an individual you would like to be on the same team with, please indicate your preference here. Requests will be considered during team placement. The content of this field is kept private and will not be shown publicly.

Shirt Size: *

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Payment Confirmation: Please enter your Pay Pal Confirmation/Reciept Number:

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I agree to the below Consent and Waiver Form.

By clicking “I agree” to the above waiver which will constitute my valid signature), I acknowledge my understanding that my participation in the 2010 Frederick Wellness Challenge and/or any pre or post-Challenge activities (the challenge and pre/post-Challenge activities are individually and collectively referred to as the "Event") may involve rigorous physical activity and that it potentially may be hazardous. I attest and verify that I am physically fit, not pregnant, and am prepared for the physical fitness aspect of this Event and that, if appropriate, my physical fitness to participate in the Event has been verified by a licensed medical doctor. I expressly assume all known and unknown risks associated with the Event, including but not limited to: loss of or damage to my property; injury (including death); accidents; the effects of weather; terrain conditions that may vary widely, and that may include uneven and/or slippery surfaces, unpredictable spectators/participants, and natural and manmade obstacles (including without limitation, vehicles, security barriers, signs, cables, mats, and debris that could be present during any portion of the Event); and the possibility that an Event may be postponed, ended early or cancelled altogether by Event or government officials. In consideration of my participation in the Event, I, for myself, my heirs, executors, administrators, personal representatives, successors and assigns (a)waive and release any and all rights, claims and causes of action I have or may have against any Challenge Organizer (as defined below) that may arise as a result of my participation in the Event; and (b)agree to indemnify, defend, and hold harmless all Challenge Organizers from and against any and all injuries, losses, causes of action, liabilities, damages, expenses (including attorney’s fees and court costs) or claims (collectively, “Claims”) that might arise directly or indirectly from my participation in the Event and/or the condition of the Event Locations, property, facilities or equipment used for the Event, regardless of when such Claim may arise including, without limitation, Claims relating to (i) theft, loss or disappearance of property, (ii) bodily injury (including fatality), and (iii) property damage, for all claims and losses (including attorney's fees and court costs), which may be brought against any one or more of them by anyone claiming to have been injured or otherwise to have suffered loss or damage as a result of my participation in the Event. For these purposes, a "Challenge Organizer" is any one or more of the following: The Frederick Wellness Challenge, Inc., Mid Atlantic Clinic: A Creating Wellness Center, LLC., Creating Wellness Alliance, LLC., Frederick City, all governmental agencies representing the territory in which the Event will be held and from which resources (such as, without limitation, fire, police and ambulance personnel)are provided; all sponsors, agents, vendors, medical personnel and contractors of or for the Event; emergency (for example, fire and police) and all medical service providers; and the officers, directors, employees, representatives, successors and assigns of each of the foregoing. I further grant full permission to any and all Frederick Wellness Challenge Organizers to store, use, reproduce and/or resell my image or likeness by any audio and/or visual recording technique (including electronic/digital) now in existence or hereafter invented, for any legitimate purpose, including commercial sales and marketing purposes. I understand and agree that information about me that is collected by the Frederick Wellness Challenge Organizers, including without limitation information in the application form, my Event results, my initial and final Wellness Quotient; excluding however any and all personal medical information that I may disclose in my Lifestyle Questionnaire, my Creating Wellness Assessment or to Event medical personnel, may not be disclosed to any third parties for any purpose other than for my own medical treatment in the event of an emergency during the course of the Event. I acknowledge and agree to abide by any Official Rules for the Event that may be posted at the Event or on the Event's website or otherwise communicated to me verbally or in writing at the Event by Event officials. I hereby represent and warrant that I am 18 years of age or older. The content of this field is kept private and will not be shown publicly.