Saturday, June 19, 2010

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 & 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  (by May 15)                               No Race # Transfers Allowed
______ $60.00 Individual Entry (May 16 to May 31)

______ $70.00 Individual Entry (June 1)

______ $10.00 1-day USAT membership per person (required if not a USAT member)
______ $90.00 Team Entry (by May 15)

______$100.00 Team Entry (May 16 to May 31)

______$110.00 Team Entry (June 1)
______ Extra gift to Hope on the Hill Foundation/Hospice (please circle your choice)
______ Total Enclosed

Please for safety & health reasons, no dogs allowed.

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