MISSION Entry Form 2006

Entry Fees - USARA members may subtract $8

TEAM: $100 per person (3-person team)

$120 per person (2-person team)

SOLO: $130

Registration Closes May 19

Total Paid: _______

ALL ATHLETES MUST SIGN A LIABILITY RELEASE AT THE RACE VENUE. Mail entry with check payable to: DINO LLC, PO Box 36395, Indianapolis IN 46236

TEAM: Co-ed___ All Male___ All Female___ or SOLO___

Team members must send entry forms together and use same Team Name at the bottom of this form.

AGE: _____ SEX: M__ F__

LAST NAME: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|

FIRST NAME: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|

STREET ADDRESS: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|

CITY: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__| STATE: |__|__|

ZIP: |__|__|__|__|__| PHONE#: (____)|__|__|__-__|__|__|__|

E-MAIL: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|

T-SHIRT SIZE: S___ M___ L___ XL___

USARA # (if applicable): |__|__|__|__|__|__|

EMERGENCY CONTACT INFO:

NAME: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|

PHONE#: (____)|__|__|__-__|__|__|__|

OPTIONAL:

TEAM/SPONSOR: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|

OCCUPATION: _______________ TIDBIT ABOUT YOURSELF: _____________________________