Registration Form Tear off and turn in this registration form with payment. Welcome to the 100 Mile Challenge! Registration Dates August 20th - September 7th Please fill this form out completely and mail or drop it off at the Christian County Health Department or YMCA with payment (cash or checks only). Make checks payable to: Christian County Health Department 1700 Canton Street PO Box 647 Hopkinsville, KY 42240 All proceeds will support community health and wellness initiatives. For additional questions, please call or email Amanda Bassingthwaite at 270-887-4160 ext. 148 or A.bassingthwaite@ky.gov Please Print Name: Address: State: Date of Birth: Sex: M F City: Zip Code: Phone: Email: T-Shirt Size: S M L XL 2X 3X 4X 5X Mileage Goal: (100, 250, 500, etc.) If you are participating as part of an organization, please list the organization s name here: How did you hear about this event? Facebook WKDZ WHOP Kentucky New Era Friend/Family Other: Waiver & Photo Release Consent I acknowledge that the Christian County Health Department carries liability insurance and does not provide health or accident insurance for its programs/special events. In consideration of my participation in the 100 Mile Challenge, I do hereby agree to hold free from any and all liability the Christian County Health Department and its respective officers, employees, volunteers and do hereby for myself, my heirs, executors, and administrators, waive release, and forever discharge all rights claims for all injuries and damages, occurred. I do hereby declare myself to be physically and mentally sound, having medical approval to participate in the 100 Mile Challenge. I HEREBY CONSENT to the use, publication and display, in whole or in part, by or on behalf of Christian County Health Department and its agents and assignees, including, but not limited to KENTUCKY NEW ERA, SOCIAL MEDIA, and Christian County Health Department, of any film, video tapes or photographs in which I or my child may be portrayed or identified. I waive all claims for any compensation for such use. I understand that permission is given for a one-time use only and that Christian County Health Department will be credited for the photograph(s). I waive all rights to inspect and/or approve any of the printed matter that may be used in conjunction with the photograph(s) and the use to which it/they may be put. Signature (Parent/Guardian signature if under 18): Date: For CCHD Use Only: $10.00 - Registration Select Payment Method: Cash Check
100 Mile Challenge Overview Congratulations on your participation in the 100 Mile Challenge! Below you will find some helpful information to ensure your success as you walk toward a healthier you! What is the 100 Mile Challenge? The goal of this challenge is to walk 100 miles (or more!) between September 1st and November 10th (approximately 1.4 miles per day). On Saturday, November 17th, there will be a celebration with food, fun, activities, and giveaways for those who have successfully completed the challenge. Registration for the 100 Mile Challenge begins on August 20th and ends on September 7th. How do I register? Stop by the Christian County Health Department or Hopkinsville Christian County YMCA. Cash or Check ONLY. Registration forms and information packets can also be downloaded at www.christiancountyhd.com and returned to the CCHD or YMCA with payment. How much does it cost? What s in it for me? Improved health Improved mobility Free t-shirt Free drawstring bag and water bottle (after completing 50 miles) Door prizes at finale event What tools do I need in order to complete the 100 Mile Challenge? Miles will be tracked using the 100 Mile Challenge Tracking Sheet. Extra sheets can be downloaded at www.christiancountyhd.com. Tracking Sheets must be turned into CCHD by November 14th for recognition. Important Dates to Remember: August 20th - Registration Begins-$10.00 September 1st - 100 Mile Challenge Begins September 7th - Registration Ends November 10th - 100 Mile Challenge Ends November 14th - Last day to turn in Tracking Sheets to CCHD for recognition. November 17th - 100 Mile Challenge Celebration
The Social Media Challenge Congratulations! By registering for the 100 Mile Challenge, you have already started the journey toward a healthier you. The Christian County Health Department wants to be along for the challenge! Post your photos, status updates, and tag your friends while using the #CCHD100MILECHALLENGE hashtag on social media. What s a hashtag? A hashtag is a simple way to connect you to all the other 100 Mile Challenge participants. Here s how it works: 1. As you log your miles on your 100 Mile Challenge Tracking Form, be sure to notice when you reach your 1st, 25th, 50th, 75th, and 100th mile. For each of these milestones, take a picture, and post your success to Facebook. Be sure to type #CCHD100MILECHALLENGE in the post and make the post public, so that others can see your success! Feel free to post to social media at any time using #CCHD100MILECHALLENGE, but definitely during these milestones! 2. This is a great way to promote a healthy competition between you and the rest of the 100 Mile Challengers. Stay positive! Be creative! Encourage others! Most of all, have fun! The Christian County Health Department will be searching for your #CCHD100MILECHALLENGE posts and frequently sharing your successes on our social media pages. If you have not already done so, be sure to like the Christian County Health Department s Facebook page or follow us on Instagram and Twitter so that you can keep up-to-date on this and other activities at the Christian County Health Department! Complete your first 50 miles, present your tracking sheet to the Christian County Health Department and receive a free bag and water bottle! Be sure to include all of your miles from the 100 Mile Challenge in the Mission to the Moon initiative! What is Mission to the Moon, you ask? Sign up today and see how to receive a free t-shirt at www.missiontothemoon.net.
Tracking Info You may track your mileage using the attached tracking sheet. If you need more tracking sheets, you can simply make a copy or download more at www.christiancountyhd.com. If you are using another method to track your miles, there is no need to fill out the entire tracking sheet. At the end of the challenge, simply print a tracking form, fill in your name at the top and the total mileage at the bottom of the page, and turn it in to the CCHD by November 14th for mileage recognition.
Tracking Sheet Name: Date Miles Date Miles Total: Total: Return this sheet to CCHD by November 14th. Share your successes on social media! #CCHD100MILECHALLENGE