STAGGERWING DUATHLON ENTRY FORM

FIRST NAME

LAST NAME

ADDRESS

CITY

STATE

ZIP

PHONE

E-MAIL ADDRESS

GENDER (M/F):

BIRTHDAY:

AGE ON 12/31/2011:

SHIRT SIZE: (S, M, L, XL, XXL)

USAT NUMBER:

RELAY

INDICATE RACE DIVISION:

INDIVIDUAL

INDIVIDUAL ATHENA

INDIVIDUAL CLYDESDALE

RELAY

You must also print, sign, and send the USAT waiver

Mail Registration to:
Joanne Elston
204 Tara Blvd
Tullahoma, TN 37388

Make checks payable to: Mach Tenn Running Club