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'THE GOLD RUSH’ MOTHER LODE FOUR DAY CHALLENGE Official Entry Form 2009 |
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MAIL TO: Team Karma, 1521 De Ve Ave , Modesto , CA 95350
Team Name:
__________________________________
MEMBERS:
1. First Name:
Last: E-mail:
Address: City: State:
Zip:
Age Race
Day: M
F Shirt Size:
(S,M,L,XL,XXL)
Phone:
2. First Name:
Last: E-mail:
Address: City: State:
Zip:
Age Race
Day: M
F Shirt Size:
(S,M,L,XL,XXL)
Phone:
3. First Name:
Last: E-mail:
Address: City: State:
Zip:
Age Race
Day: M
F Shirt Size:
(S,M,L,XL,XXL)
Phone:
4. First Name:
Last: E-mail:
Address: City: State:
Zip:
Age Race
Day: M
F Shirt Size:
(S,M,L,XL,XXL)
Phone:
ENTRY FEE: $395.00/person, ($310 under 25). (3 Person team $1185, 4 person $1580) $
LATE ENTRY: After
TOTAL FEE SUBMITTED (checks payable to ‘
RACE IS LIMITED TO 25 TEAMS
LIABILITY WAIVER: In
consideration for accepting my entry, I, intending to be legally bound, hereby
for myself, my heirs, executors and administrators,
waive and release any and all claims against persons and organizations
affiliated with the race, Gold Rush
Mother Lode, while participating or traveling to or from the race. I further attest that I am physically fit for
this race and am able to swim
Signature Team Member 1 Date:
Signature Team Member 2 Date:
Signature Team Member 3 Date:
Signature Team Member 4 Date: