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Participant Information

* Designates required fields
Company / Organization Name
* First Name
* Last Name
* Age on 6/3/11:
* Sex M / F
* Address
* City
* State
* Zip
* Work Phone
* Home or Cell Phone
* Email
* Shirt Size
* I Accept the Terms and Liability waiver & release.


Payment Information

All fields required

$35.00 Registration Fee
Card type:
Card Number

Name On Card
Security Code
Valid Through
Credit Card Address 1
Credit Card Address 2
Credit Card City
Credit Card State
Credit Card Zip
Credit Card ZipExt
Credit Card Phone Number
Credit Card Country


Terms and Liability waiver and Release: Upon acceptance of my entry, I, for myself, my heirs and assigns, hereby release the sponsors and officials of the Chamber Challenge from any and all liability arising from illness, injury or death I may suffer as a result of my participation in these events. I attest that I am physically fit and have sufficiently trained for these events and I am aware that my participation could, in some circumstances, result in personal injury. Should officials determine the completion of this event to be injurious to my health, I consent to be removed and treated by the physician in attendance or of their direction. I also consent to my removal in the event that I violate the prohibition of strollers, bikes, skates or other wheeled device or if I in any way endanger the safety of others. I give permission for free use of my name and picture in any broadcast, telecast or written account of these events. I understand that the entry fee is NON-REFUNDABLE.br />
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