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Fitness Challenge

Fitness Challenge Registration

May 19, 2012

Fitness Challenge Registration

Northern Virginia Criminal Justice Training Academy
2012 Fitness Challenge Registration Form

Registration Fee is $20.00 (Checks Made Payable to Special Olympics Virginia), payment must be received by Friday, September 14, 2012 .

Send To:
NVCJTA
Fitness Challenge
45299 Research Place
Ashburn, VA 20147

Competition Day is September 15, 2012

*Name:

*Shirt Size:

*Agency:

*Email:

*DOB:

*Sex:

*Are you presently taking any medications?:

Yes
No

If so, please indicate what medications and the reason(s):

I understand that the NVCJTA Fitness Challenge involves maximal physical exertion. I understand that NVCJTA is not liable for any injury or health problems related to my participation in this competition. I hereby take full responsibility for any accidents or injuries that may occur.

*I accept the terms:

*Current Date:

*Emergency Contact Name:

*Emergency Contact Phone Number:

45299 Research Place, Ashburn, VA 20147 (view map) | (703) 729-4299 | Fax (703) 729-4634

Fitness Challenge Registration

Northern Virginia Criminal Justice Training Academy 2012 Fitness Challenge Registration Form

Northern Virginia Criminal Justice Training Academy
2012 Fitness Challenge Registration Form