Q50 RACES

Full Moon USA 2012 - 5 Mile Night Race - Registration

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Q50 RACES: FULL MOON IN TEAMS OF 2 RUNNERS TRAIL RUN!

ENTRY FEES:

REGISTER NOW!

THE PRICE IS FOR THE 2 RUNNERS!!

ENTRY FEES: (PER TEAM)	5 Miles
December 15th, 2011 – April 1^st, 2012	$60.00
April 2nd – June 1^st, 2012	$75.00
June 2^nd – July 1^st , 2012	$95.00
July 2nd – August 3rd, 2012	$110.00
Race Day! August 4, 2012	$120.00

Active: http://www.active.com/running/mandeville-la/q50-races-5-miles-full-moon-2012

WE WILL HAVE RACE DAY REGISTRATION FROM 7:00 PM TO 7:40 PM

Please note: T-shirts are not guaranteed for entries received within two weeks of the event.

ONLINE REGISTRATION: Complete the online registration form (available at the bottom of the race

details).

PAYMENT:
**BY MAIL: Mail registration form and a CHECK written to INTERQUEST EXPORTS AND IMPORTS,

INC. to the following: 201 St. Charles Av. Suite 114-364
New Orleans, LA 70170

You will receive entry confirmation by email once payment is received.

**WIRE TRANSFER: Respond to welcome email from info@q50ultras (this email is sent after

completion of online registration form) that you would like to pay via wire transfer. We will reply with

the wiring instructions of our USA Bank Account/ Please, include your First and Last Name and your

email address as the reference on the wire transfer. You will receive entry confirmation by email once

payment is received.

**PAYPAL: Respond to welcome email from info@q50ultras (this email is sent after completion of

online registration form) that you would like to pay via paypal. We will reply to you with a payment

request form. Easy!

CAN'T WAIT TO SEE ALL OF YOU IN FONTAINEBLEAU STATE PARK IN BEAUTIFUL MANDEVILLE,

LOUISIANA!!

If you have any questions about Q50 Ultras events, please don't hesitate to contact us at

info@q50ultras.com or 504- 390-8807. We will be happy to provide any additional information you

might need.

Thank you!.

I want to register for?

Your Name and Last name: (*)

Your email: (*)

Phone number: (*)

Address : (*)

ZIP Code: (*)

City/State and Country: (*)

Birth Date:
/ / (DD / MM / AAAA)

Passport number or D.N.I.:

Medical Insurance:

Medical Insurance Phone (and # if necessary):

T-shirt size:

Please list below any medical or physical condition(s) that should be noted by the Medical Director. Please describe any medical/physical conditions that may affect your ability to safely take part in this event and list any medications that you are routinely taking. Also please mention if you are allergic to any insects, or medicines. List N/A if no conditions exist.

Name and telephone number of relative or friend who can be called in case of emergency:

Name and telephone number of relative or friend who can be called in case of emergency 2:

The Other Team Member Information.

Your Name and Last name:

Your email:

Phone number:

Address :

ZIP Code:

City/State and Country:

Birth Date:
/ / (DD / MM / AAAA)

Passport number or D.N.I.:

Medical Insurance:

Medical Insurance Phone (and # if necessary):

T-shirt size:

Please list below any medical or physical condition(s) that should be noted by the Medical Director. Please describe any medical/physical conditions that may affect your ability to safely take part in this event and list any medications that you are routinely taking. Also please mention if you are allergic to any insects, or medicines. List N/A if no conditions exist.

Name and telephone number of relative or friend who can be called in case of emergency:

Name and telephone number of relative or friend who can be called in case of emergency 2:

WAIVER:
I hereby confirm that I have read the Q50 Ultramarathon Rules and Regulations and voluntarily sign this waiver. I confirm my agreement to assume the entire risk of any loss, property damage, illness, injury, contact with other participants, damages caused by weather conditions and geographical obstacles, or death that I may sustain or cause as a result of my participation on the Q50 Ultramarathon (the “Event”). I understand that my participation in the Event may include participation in activities which demand a very high level of skill and physical and mental fitness. I confirm that I register on the Event declaring to be medically able and properly trained. I hereby assume responsibility to follow any decision given by an organization official or doctor relative to my ability to complete the race. Having read this text and having acknowledged possible consequences and considering my acceptance in participating in the Event, I hereby, under my name and under any person that may represent me, release and discharge Q50 Ultras Organizers, local authorities related to the event and all Oficial Sponsors that intervene in the Event, contractors, representatives and successors, from present and future claims and liabilities of any kind, known or unknown, arising out of my participation on this event or related activities, even though such claim or liability may arise out of negligence or fault on the part of any of the forgoing persons or entities. I grant permission to the foregoing persons or entities to use any photographs, motion pictures, recordings, or any other record of my participation in this event for any legitimate purpose without remuneration.