Shape Up Windom 2011 Entry Form

Shape Up Windom is a local contest created to help increase the health and vitality of the Windom Community. This 3 month contest will encourage the contestants to eat healthfully, exercise regularly and reach weight loss goals. Cost for each participant is $30. $5 of each entry will be donated to the local food shelf. 95% of the remaining funds* will go to the champion crowned on January 3, 2012! Each participant must be weight certified by a professional (doctor, fitness trainer, weight watchers weigh-in). Fill out entry form and return to address below. Then, hit the gym, count those calories or whatever it takes* to get in shape!
*5% of remaining funds will be used as seed money for upcoming year publicity
* Please, no surgical procedures allowed for weight loss competition.

Remember, always check with your health care professional before starting any exercise routine or diet. Name: DOB: ___________ Address: City/State/ZIP: E-mail: Phone: ( ) Starting Weight: _______ Date: _______ Certified by: _________________________ I, ______________________________, certify that the above weight is my actual weight certified by a professional.
Mail in contest entry form and fee to: Elizabeth Grave 968 Prospect Ave Windom, MN 56101
Mark One

check included cash included Make Checks payable to Elizabeth Grave. Questions? e-mail elizabethagrave@gmail.com call - (507) 831-4750

--------------------------------- For Contest Use Only ---------------------------------------Name: ____________________ Starting Weight: ____________ Final Weight: ______________ Pd: __________________