Miramonte Cross Country-OLD

Thank you all that have passed your name onto me. Colby Powell, our Orinda Road Runner contact, has asked that for those who would like to sign up for this race, that you fill out the information below and on the attached application (this is from 2011 so please cross out ‘2011’ and ‘June 12’ and write in ‘2013’ and ‘June 9’ for the date wherever it appears prior to signing. The price is now $75. The application must be signed by a parent/guardian if under 18.

We need the following info and a check for $75 made out to ‘Dipsea Race’ delivered to 1071 Glen Road by 4PM on Friday, 3/15/13:

First Name:

Initial:

Last Name:

Address:

City:

State:

Zip:

Telephone (Day):

Telephone (Evening):

Fax:

Email:

Age on Race Day (6/9/13):

Birthdate:

Gender (M/F):

Current High School:

Club (Orinda Roadrunners):

T-shirt: MEN s m l xl

Number of Dipseas completed:

Consecutive:

Explanations, sad stories, pleas & bribes:

Emergency Contact Name:

Emergency Contact Phone: