| ENTRY FORM | ||
| First Name: | Last Name: | Date of Birth: |
| Home address: | ||
| City: | State: | ZIP: |
| Mother's Name: | Phone #: | |
| Father's Name: | Phone #: | |
| Home phone #: | E-mail: | USCF rating: |
| Emergency Contact: | ||
| Weeks' numbers: 1 2 3 4 5 6 7 8 9 Please check the week(s) number(s) | ||
| Site: | ||
| TOTAL ENCLOSED $________ | ||