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Entry
Form
Name: ________________________
Age: _______
Sex: _____ T-shirt size: (Note:Loose Fit)___________
Address: __________________________________________________________________________________ City: __________________________State/Zip: __________________
Phone: ________________________
E-mail (for confirmation): _________________________
Emergency Contact Person and Phone: ___________________________________________________ Total enclosed: __ $25 fee for 10K
__ $30
fee for 1/2 Marathon
Note: $5 per vehicle fee to enter the Tombigbee National Forest Choctaw Lake
Waiver:
In consideration of my entry into the Choctaw Challenge, I do hereby, for myself, my wards, dependents, heirs, executors and
administrators assign, waive, and release from indemnity for damages and possible injury or loss, I or they may now, or in
the future suffer or have against the Tombigbee nation Forest or the organizers and/or sponsors on this event on May 17 2008, including, but not limited to U.S. Forest Service, their employees,
agents, representatives, successors and assigns, I further agree to allow the organizers and /or sponsors of this event, including but not limited to their employees,
representatives, successors, and assigns to photograph me, using either still or motion videotape of my participation in the
Choctaw Challenge before, during, or after the actual conduct of the event. I
attest and verify I am fully aware of the rigors and difficulties I may encounter in cross-country running and hiking and
fully understand that I may become injured, partially or wholly, as a result of my participation in said event in question
to be held May 17 2008. Furthermore,
I accept the risk of injury, and understand that the choice to assume that risk is my responsibility, and do hereby verify
that I am physically and mentally fit to participate and complete the race. Signature: ___________________
(Parent or Guardian if under 18)
Date: _______________________
Mail with payment to:
Choctaw Challenge
C/o Mann Conrad
117 Kirkside Drive
Starkville, MS 39759
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