2005 Prairie State Tandem Rally

Two Wheels, Four Legs, Endless Corn

Registration and Waiver

Captain		Age
Stoker		Age
Additional Rider #1		Age
Additional Rider #2		Age
Additional Rider #3		Age

Address
City, State, Zip
Phone
Email

What bicycle club, if any, are you a member of?

Tandem make:

Tandem Model:

There will be a limit of 150 total people for the dinner Saturday!!

	Quantity	Cost Per Person	Total Cost
Entry Fee		$6.00
Dinner Saturday, June 4	--------	--------	-----
Adult Dinners		$13.00
Child (Under 9 yrs of age) Dinners		$7.50
		Total for Entry Fees and Dinner è

TEE SHIRTS (Not Available After May 1)

Please fill in the quantity of each size you are ordering

	Small	Medium	Large	X-Large	XX-Large	Total Cost
Adult S-XL ($12.00)					-----
Adult 2XL ($14.00)	----	------	---	---
				Tee Shirt	Total è

Grand Total è

Registration due by May 1, 2005. Entry fee increases to $11.00, dinner increases to $18.00/ $9.00, if there are still not 150 signed up. Tee shirts will no longer be available.

Make checks payable to: PRAIRIE STATE TANDEM RALLY

Mail forms and payment to:

Jeff Cox

3370 W. Main St.

Decatur, IL 62522

If you would like a confirmation by mail, please send a self-addressed, stamped envelope with your registration, otherwise confirmation will be sent via email.