Name of Track and/or Event:
Event Date(s):
/
Month
/
Day
Year
Date
Guardian
Father
Guardian
Mother
Date (mm/dd/yyyy)
/
Month
/
Day
Year
Date
I represent that I have sole legal custody or am sole parent/guardian.
I represent that I have sole legal custody or am sole parent/guardian.
Printed Name of MINOR Participant:
Date of Birth of MINOR Participant
Address of Participant:
Printed Name of Parent or Guardian:
Signature
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