 |
 |
|
| 11th Annual Tennessee State Rally | ||
Registration Form
Proceeds Benefit St Jude Children's Research Hospital
June 3rd - June 5th, 2011
| Rider: |
________________________________________ | |||
| Passenger: |
________________________________________ | |||
| Address: |
________________________________________ | |||
| City, ST, ZIP |
________________________________________ | |||
| Telephone #: |
________________________________________ | |||
| EMail Address: |
________________________________________ | |||
| Chapter Name: |
________________________________________ | |||
| Officer (Y.N): ______ | Position: ______________________________________ | |||
| Will you bring Children 18 or under: __________ | How many & Ages: ______________________________ | |||
|
Cost |
Qty |
Extended Amount | ||
|
Full Registration: Includes 1 T-Shirt, 1 Poker Run & 1 Pin |
$20.00 |
ea |
____ |
________ |
| Extra Individual T-Shirts |
$10.00 |
ea |
____ |
________ |
| Extra Poker Runs | $5.00 |
ea |
____ |
________ |
| Extra Individual Pins |
$5.00 |
ea |
____ |
________ |
|
Total: |
__________ | |||
T-Shirts (Specify Quantity)
| S Qty | M Qty | L Qty | XL Qty | 2X Qty | 3X Qty | 4X Qty | 5X Qty |
| ________ | ________ | ________ | ________ | ________ | ________ | ________ | ________ |
To Preregister, Print this Page, Complete (including Waiver Below) and mail along with check for total amount
made payable to:
"Bill McEachern" with "TNRally11" in remarks to:
William McEachern
1345 Maria St.
Memphis, TN 38122
OR
Pay By Paypal by clicking on following link:
RELEASE AND WAIVER OF LIABILITY
AND INDEMNITY AGREEMENT
A Waiver must be signed at the Rally Registration Table by all Participants