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10652-8030-1301 This information is maintained on file during the event in case an incident occurs requiring a participant to receive emergency medical treatment. FIRST NAME LAST NAME EMERGENCY CONTACT NAME TELEPHONE NUMBER HEALTH INSURANCE PROVIDER, GROUP NAME TELEPHONE NUMBER ACKNOWLEDGEMENT I acknowledge and assume all risks associated with this event including, without limitation, falls, animal bites, food poisoning, accidental needle sticks, effects of weather, including heat and hum.

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