Region A
Mississippi District Rally
2010 Registration Form
Rally Date Oct. 14, 15, 16 2010 Tupelo, MS GWRRA
Rider Name:
Address:
City:
State:
Zip:
E-mail Address:
GWRRA #:
Date of Birth:
Check:
Male or
Female
Phone:
State & Chapter:
Miles to Rally:
Check:
Rider
Solo
2up ---
Wing
Trike
Sidecar ---
Other
Co-Rider Name :
GWRRA #:
Date of Birth:
Check:
Male or
Female
Check:
Co-Rider
Solo
2up ---
Wing
Trike
Sidecar ---
Other
Children under 15 free with registered adult. Please use separate sheet for names.
GWRRA Members $25 (on site fee $30.00)
@ $25 =
Non GWRRA Members $30 (on site fee $35.00)
@ $30 =
50/25/25 Tickets: 14 Tickets for $10
@ $10 =
50/25/25 Tickets: 6 Tickets for $5
@ $5 =
Grand Prize Tickets: $2 ea.
@ $2 =
Med 1st Recertification : $20
@ $20 =
Advanced Rider Course: $20
@ $20 =
Experienced Rider Course: $20
@ $20 =
Trike Course: $35
@ $35 =
Will you be attending Thursday Night Meal ?
Yes
No
Is this your First MS District Rally ?
Yes
No
Rally Shirts (Polo)
S-
M-
L-
XL-
Shirts
@ $20 =
XXL-
XXXL-
XXXXL-
Shirts
@ $22 =
Rally Shirts (Long Sleeve Tee)
S-
M-
L-
XL-
Shirts
@ $18 =
XXL-
XXXL-
XXXXL-
Shirts
@ $20 =
Rally Shirts
(Tee)
S-
M-
L-
XL-
Shirts
@ $16 =
XXL-
XXXL-
XXXXL-
Shirts
@ $18 =
Cash, Check or Money
Order Accepted for Registration.
Sub Total =
ONLY MasterCard & Visa Will Be
Please Add 5% for Credit Card =
Accepted for Registration.
Grand Total =
CC#
Expires:
CC Authorization Sign Here:
Waiver: I/We agree to hold harmless GWRRA, Co-sponsoring Organizations and any property owners
for any loss or injury to self or property in which I/We may become involved in by reason of My/Our
participation in this Rally/Convention. Witness My/Our signatures this date on the line(s) below.
Signed Rider:
Date:
Signed Co-Rider:
Date:
Print out and mail with Credit Card info or check or money order.
Thank You
No Refunds after Oct. 1st ($5.00 serv. fee)
Make payable to:
Mississippi GWRRA
Form Instructions:
(1) Fill the form out and Print to mail :
(2) Mail to : Rosemary Patterson
2247 Hwy 35 S
Foxworth, MS 39483