7^th Annual Mineral Belt 10km Nordic Tour

ENTRY FORM

Last Name __________________________________________________________

First Name _________________________________________________________

Mailing Address _____________________________________________________

City _______________________________________________________________

State ________________________ Zip Code ______________________________

Phone ______________________________________________________________

Classification (Please Circle One)

SEX                                                  AGE CATEGORY

Male           Female                          18-25         26-40         40+

Medical & Emergency Information

Major Medical Problems in Last 2 Years:

___________________________________________________________________

Are you currently taking any medications?       YES           NO

If YES, please list. ___________________________________________________

Person to contact in case of emergency:

Name ______________________________________________________________

Relation ____________________________________________________________

Phone ______________________________________________________________