2008 Katcina Mosa 100K Mtn Challenge Run

1.While on screen "TYPE" IN ALL VALUES 2. then PRINT, SIGN & MAIL WITH CHECK.

Name:
Address:
City: State: Zip:
Country:
Birth Date (mm/dd/yy) Age on 8/02/2008 Sex:
Day Phone Eve Phone:
Emergency Phone Contact Person:
Email: Short sleeve T-shirt
4 Member Team
Each member fill out seperate application at least one male or female
Husband/Wife Team
List Last Names
,,,
# Marathons finished
# of ultras finished: Best 50M 100K Trail time in last 2 years:
Kat'cina Mosa's finished '02 '03 '04 '05 '06 '07
Will you be at
Fri Pre Race Dinner?
Extra Friday Dinners @ $5.00 x
Extra dinners for Sat BBQ @ $5.00 x Kids Meals (Fri or Sat) @ $2.00 x
Addit'l Tshirts Size Qty. Size Qty. x $15.00=
Tank Top Size Qty. Size Qty. x $10.00=
Race Entry Fee enclosed:
No entries accepted after July 12 Postmark
Total Due:

WAIVER: I realize that there are risks associated with competing in this event and in your consideration of accepting this entry, I, the below signed, intending to be legally bound for myself, my heirs, executors, and administrators, waive and release any and all rights and claims for damage I may have against any persons, officials, private property owners, organizations and/or sponsors of the Katcina Mosa 100k Mtn Run and their representatives, successors, and assigned for any and all injuries suffered to me in this event even though liability may raise out of negligence or carelessness on the part of any persons named in this waiver. Further, I grant full permission for any and all of the forgoing to use photographs, videotapes, motion pictures and recordings of me for any legitimate reason. Also, I understand that the race director and/or race officials, have the right to reject any entry and to pull anyone from the run who litters on the course outside of the aid stations.

Signature_________________________________ Date_______________ amazing counters Musicians Friend

Check payable to "KM100K" and Mail to: Katcina Mosa 100K, 1802 N Heather Dr., Orem, UT 84097