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I wish to enroll my son/daughter in the 2010 Mark Mirabelli's Track & Field Clinic. I understand that neither Peddie School, the director, nor anyone connected with the Mark Mirabelli Clinic will assume any responsibility for accidents, medical, dental, or other expenses incurred as the result of accidents sustained during or as a result of any course of instruction given the applicant by the clinic staff. I hereby authorize the guardian, coach, or director to act on my behalf according to his/her best judgment in any emergency requiring medical attention.
Signature of Parent ____________________________ School ____________________________
Applicant's Name _____________________________ Age ____ Male ____ Female ____
Street Address _____________________________ City _____________________________
State _________ Zip Code _________ Home Phone ___________________________
Event ______________________________________________ Shirt Size M L XL XXL
Email Address ______________________________________________
First 100 mail-in registrations will be given a free t-shirt (M, L, XL, XXL)
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