Hozhoni Days/Earth Week 5K Run/Walk
Saturday March 27, 2004

Name:___________________________________        Age:____         Sex:_______

Address:_________________________________         Date of Birth:________

City:____________________________ State:________

E-mail address:_____________________________

Zip Code:____________                (Check one) 5K run:_____ walk:_____

Circle One:  13 & under         14-19         20-29         30-39         40-49         50+

Release:

Please read carefully before signing! Signature:___________________________________

I am aware that participation in the 5^th Annual Hozhoni Days/Earth Week 5K Run & Walk can be dangerous and may involve Risk of Injury or Death. I understand that by participating in this activity, I may be exposed to such risks and dangers, such as Acts of God, inclement weather, environmental conditions, etc. I further understand that my participation in this activity, as well as travel to and from related events, may result in serious injury and may impair my future abilities to earn a living or to engage in other business, social and recreational activities. Given all of these risks, however, I still intend to participate in this activity. By my signature, I hereby release and hold harmless the State of Colorado, the Board of Trustees for Fort Lewis College, And Fort Lewis College, its officers, faculty, employees, and agents (Collectively Fort Lewis College), from any and all liability that may arise from my participation in the above-referenced activity. I further agree not to sue, or otherwise assert claims, against Fort Lewis College arising from my participation in the above-referenced activity.

I further Understand and represent that:

1. This document has specific legal implications and I have had the

opportunity to have council review this document before I have signed.

2. While participating in this activity, I am subject to all Fort Lewis College

policies and procedures, including the Student Conduct Code; I will follow

directions and guidelines from Fort Lewis College staff.

If under eighteen years of age (Parent/Guardian Signature & Notary Required); see below

Mail Completed and Signed Registration before March 23, 2004

$10.00 (Check or Money Order Payable to Fort Lewis College)

(After March 23 $15.00) to:

Wanbli-Ota Club
Native American Center

118 Miller Student Center
Fort Lewis College
1000 Rim Drive
Durango, CO 81301

(The Environmental Center is located in room 202, on the Second Floor
of the Student Union Building)

Contact:

(970) 247-7221 or (970) 247-7676

________________________________________________________

Signature Parent/Guardian - Signature (if required, must be notarized)

________________________________________________

Printed Name

________________________________________________

Address/Phone

________________________________________________

Date

STATE OF ____________________________________________

COUNTY OF __________________________________________

Subscribed and sworn to before me this _______________ day of

_____________, 20___, by _______________________________

My Commission Expires: ________________________________

______________________________________________________

Notary Public