Last Name First Name Age on Sex
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April 19 M/F
Mailing address (include apt. # and c/o)
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City and State Zip/Postal Code
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Birth date Area Code Telephone
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Mo Day Yr
E-Mail Address
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WAIVER. I am properly trained and enter this race totally at my own risk and hereby
waive all claims that I or my heirs may have against all sponsors, race directors and
all others associated with this race, for any injuries or problems I may sustain,
regardless of any negligence. I am totally responsible for my safety and any injury
I may suffer.. Further, I hereby grant full permission to any and all of the foregoing
to use my name, likeness and voice, as well as any photographs, videotape, motion
pictures, recordings and any other record of this event in which I may appear for any
legitimate purpose including broadcast of the event, the reuse in any media of this
broadcast and in advertising and promotion.
Signature(by parent or guardian if
participant is under 18) ___________________________________________________
MAIL ENTRY FORM WITH $20 BY April 18 TO
Dystrophy Dash 5k
c/o Mary Dahle
White Bear Lake High School/South Campus, 3551 McKnight Ave, White Bear Lake, MN 55110
Make check payable to White Bear School District
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