SR 1/2/3 Registration

Mississippi Gran Prix

2009 Senior 1 2 3 Race

TEAM ENTRY FORM

To make this year's race a 5-day challenge, we must receive a commitment from at least 10 teams made up of 6 to 8 members. There is a maximum field limit of 17 teams. A $250 non-refundable deposit must be received by February 15, 2009. The deposit will be applied toward race entry fees.

TEAM NAME:

_____________________________________

CONTACT PERSON:

_______________________

PHONE#:

______________________

EMAIL:

____________________________________________

Cat

First Name

Last Name

Birthdate

Day Phone

Evening Phone

Address

City

State

Zip

Race Age As of 12/31/09

USCF#

Club Name

Emergency Contact

Emergency Contact Phone #

All deposits must be received by 2/15/09. A Final Team Memeber list with all of the above infomration filled out must be received by April 10th. Please mail the entry form above with at least the team contact information completed and the $250 deposit to the following address:

MS GRAN PRIX

Attn: Jennifer Legg

P. O. Box 873

Brookhaven, MS 39602