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DALLAS COUNTY HEALTH DEPARTMENT

1011 W Main Buffalo, MO 65622 417-345-2332

Shape Up Registration

Fall Shape Up Dallas County 2019

Name ___________________________________________________________________

Address _________________________________________________________________

City _________________________________________     MO  Zip _________________

Phone_________________________________________________________

Email _________________________________________________________

T-Shirt Size:  □ S    □ M    □ L    □ XL    □ 2XL    □ 3XL    □ 4XL     □5XL

(T-shirts will be awarded as weekly prizes, please select a size should you be a weekly prize winner)

Disclaimer:  I understand that I must weigh in weekly on the assigned days to be eligible for prizes offered. I realize that any attempt to manipulate the weights would result in automatic disqualification at the discretion of the sponsors. Only safe and approved methods for weight loss are encouraged. If you have any underlying medical conditions or have never started a weight loss program we encourage you to seek a doctor’s advice prior to beginning the program. The sponsors of this challenge are not responsible for any health related issues that might arise as a result of participation. The goal of this contest is to promote community wellness and encourage healthy behaviors. All results will be final and are indisputable

Print Name ___________________________________

Signature _____________________________________

Date___________________________________________

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