Region A  Mississippi District Rally 2008 Registration Form 
                        Rally Date Oct. 16, 17, 18  2008

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. For other use separate sheet.
Name:                    Birth Date:    Check: Male  or Female
Name:                    Birth Date:    Check: Male  or Female
Name:                    Birth Date:    Check: Male  or Female
GWRRA Members (on site fee $30.00)                                           @ $25 =
Non GWRRA Members (on site fee $35.00)                                   @ $30 =
50/25/25 Tickets: 13 Tickets for $10                                             @ $10 =
Grand Prize Tickets: $5 ea.                                                               @ $  5 =
Med 1st (CPR / First Aid combo): $20                                             @ $20 =

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