registration begins 22nd Jan and ends 4th Feb 2010

“CHWC” Session #3 Feb 8th to 3rd May 2010

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Name________________________________________________Age_____

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Phone___________________EMail_________________________________

Emergency Contact & Phone ______________________________________

Allergies/Medical/Other conditions we should be aware of: ________________________________________________________________________________________________________________________________________________________________________

________________________________________________________

Liability Release:  “I, the undersigned, hereby certify that I am physically fit and have not been otherwise been informed by a physician.  I acknowledge that I am aware of all the risks inherent in physical activities, including various injuries.  I HEREBY WAIVE ANY AND ALL RIGHTS TO CLAIMS FOR LOSS OR DAMAGES, INCLUDING ALL CLAIMS FOR LOSS OR DAMAGES CAUSED BY THE NEGLIGENCE, ACTIVE OR PASSIVE OF ISLAND ATHLETIC EVENTS, LLC dba SAN JUAN ISLAND FITNESS, HOST FACILITIES, OR ANY INDIVIDUALS VOLUNTEERING OR SUPERVISING SUCH ACTIVITIES.  Finally, I specifically acknowledge that I am aware of all the risks inherent I agree that I won’t sue ISLAND ATHLETIC EVENTS, LLC dba SAN JUAN ISLAND FITNESS; it’s employees or agents for anything.  My participation in the “Community Healthy Weight Challenge” is my decision and I hereby acknowledge my personal responsibility for my decisions and me. I understand there are no refunds for this event for any reason.

Signed______________________________________________________date_________________________

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_____Entry - $75

_____Entry – $65

_____Entry - $55

_____    Option #1 – $96 Non Pool

_____    Option #1 – $120 Pool

_____    Option #2 – $180 1x Weekly Nutrition Counseling

_____    Option #3 – $120 1x Weekly Personal Training

_____    Option #4 – $180 2x Weekly Personal Training

_____    Option #5 – $300 3x Weekly Personal Training

_____    Option #6 – $480 Club Member Total Package (Includes Entry Fee)

_____    Option #6 – $600 Challenger Total Package (Includes Entry Fee)

_____    Option #7 – $180  - 36 Class Punch Card