Saturday, June 20, 2009

Limit:   500

Last Name: ______________________________ First Name: __________________________

Address: _____________________________________________________________________

City: ________________________________________ State: ________ Zip: _______________

Phone No: ______________________   Date of Birth: ____/____/_______ Age on race day:_________

Sex: ( M__ ) ( F__)                                                          Circle shirt size:   S   M   L  XL

I own my own chip # __ __ __ __ __ __ __         Email Address:___________________________

Are you a USA Triathlon member? ( Y__ ) ( N__ )           My number is: __________________

Team Name: ______________________________         Team entries must be sent in together.

Waiver: I know that participating in a triathlon is a potentially hazardous activity & I should not enter this event unless I am medically able & properly trained. I assume all risks associated with participating in this event. In consideration of your accepting my entry, I for myself and anyone entitled to act on my behalf, waive & release all organizers & sponsors of this event from all claims of liability of any kind arising out of participation in this event.

Participant's Signature: ___________________________________________ Date:____________

Parent's Signature if under 18: ______________________________________ Date:____________

Fee:
______ $50.00 Individual Entry                                                                          No Race # Transfers Allowed
______ $10.00 1-day USAT membership (required if not a USAT member)
______ $10.00 Late Fee (after June 1)
______ $90.00 Team Entry
______ Extra gift to Hope on the Hill Foundation/Hospice (please circle your choice)
______ Total Enclosed (Tax Deductible)

Please for safety and health reasons, no dogs allowed.

Payable to: Johan's TriFest   Mail to: Johan's TriFest
  P. O. Box 1482
 Grand Rapids, MI 49501