SPONSORS
Friday, August 14, 2009  - Registration 3-4pm
Event 4-9:30pm        
Sign-up Deadline: Tuesday, July 14th
Missoula Sign-Up
Address:
Your name:
City:
Email:
Zip:
State:
Phone:
Alternative
Phone:
 How did you hear
about us?
Medical Information:
Phone:
Emergency
Contact:
Phone:
Doctor
Info:
Medical
Insurance:
Insurance Company                    Policy #                     Exp. Date.                 Policy Holder's Name
Medical, Physical, or Emotional Conditions (including allergies and disabilities)?
If  Yes, please provide information to assist us:
Medication?
Medications (including inhalers):
Are you up-to-date on all state-required immunizations?
If No, please explain:
Please list any other information relevant to participation:
Chicks n Chaps™ Event  ~  Friday, August 14th, 2009 (ages 21 and over ONLY)
Registration through July 14th ~ $60.00 per Chick
I would like to donate in addition to my registration fee to TETWP
T-shirt size (These are Women’s tees so please consider that when choosing size
Birthdate (MM/DD/YEAR):
YOU MUST BE 21 YEARS OLD TO PARTICIPATE!
You will be directed to the payment page when you "SEND".
Absolutely NO refunds allowed once you have registered.
NOT valid without your payment.
If you prefer, you can DOWNLOAD a printable PDF sign-up form and send by postal mail.
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