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

Shape Up Registration

Fall Shape Up Dallas County 2018

Name ___________________________________________________________________________

Address ______________________________________________________________________                          City _________________________________________ MO       Zip _____________________

Phone________________________________________________________________________              Email _________________________________________________________________________

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

(T-shirts will be provided to the top 10 percent in the weight loss division, any participant opting to order a shirt should see the enclosed order form, orders and payment due to Dallas County Health Department no later than Friday, September 14, 2018)

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 ________________________________________________________________________________












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