Plattsburgh Rotary

Second Annual Bed Races to Roll
2011 Official Entry Form

Saturday, Sept. 10, 2011

Each Team Member must complete a Waiver Form

Standard Release - Parent Release

Name (Team Contact)*	Required.	Team Name
Address 1*	Required.	Team Sponsor
Address 2		Team Member #1
City*	Required.	Team Member #2
State*	Required.	Team Member #3
Zip Code*	Required.Invalid format.	Team Member #4
Daytime Phone* (xxx) xxx-xxxx	Required.Format (000) 000-0000.	Team Member #5
E-mail Address*	Invalid format. Required.	Alternate Member #1
Team Theme		Alternate Member #2

To use a Rotary supplied bed there will be a fee of $25 and if you choose to use your own bed the $25 deposit will be refunded after the event.
Choose your Bed Fee	Use Supplied Bed Use Own Bed
Total to be charged to Credit Card		* Denotes Required Fields
Charge to:
Name on Credit Card*	Required.
Credit Card Number*	Required.Invalid format.	Three Digit Security Code*	Required.Invalid format.
Expiration*	Month Year

By clicking the SUBMIT button, I agree to abide by all of the Rules & Regulations of the 2011 Bed Race.

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