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Please Print this Form And Mail it in with your Check Or use BikeReg for credit card registrations with no service charge!!
Name: _______________________________________
Address: _____________________________________
_____________________________________________
Phone Number: ________________________________
Email (print neatly, we need a valid email):
_____________________________________________
Emergency Contact Name/Phone Number:
_____________________________________________
_____________________________________________
RUSA Number for brevet credit: __________________
Age at time of event: ____________________________
Entry Fee: $200 covers all Four Days
Mail check payable to:
Mark Frank 59 Bay Knoll Rd Rochester, NY 14622 |