White Pine Stampede 2010 Registration Form

Name		Birth date		Age*
Address
City		State		Zip
Phone		Country		Sex
E-Mail

Choose Event:	10km	20km	40km
Classification:	Classic	Freestyle
Would you like to receive results via e-mail?
Skier age group (as of January 1, 2010)	(Please choose one) 13-17 yrs 18-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70+

Entry Fees:
(NO REFUNDS)

By December 15	By January 1	After January 1	February 1st and 2nd	10km tour
$50	$55	$60	$65	$35

T Shirt Size

S

M

L

XL

I enclose $ for entry to the White Pine Stampede. My cancelled check will serve as my receipt (please do not send cash). Money orders or checks should be made payable to: WHITE PINE STAMPEDE OF MICHIGAN.

In addition, I would like to make an additional $ contribution to the Children's Hospital of Michigan.

ATHLETE'S RELEASE: I, the undersigned, know that Alpine and Nordic skiing are action sports carrying significant risk of personal injury. Racing, jumping, or freestyle competition are even more dangerous. I know that there are natural and man-made obstacles or hazards, surface and environmental conditions and risks which in combination with my actions can cause very severe or occasionally fatal injury. I agree that I, and not the ski race or its staff, and/or its clubs, officials or sponsors of the WHITE PINE STAMPEDE COMMITTEE, am totally responsible for my safety while I participate or train for these events. (Parental signature for applicants under 18.)

Signature __________________________________________ Date _____________

Choose one: MasterCard  Visa

Card Number Exp Date

After filling out this form, please print it, sign it, and mail it with your check to:

White Pine Stampede
P.O. Box 330
Mancelona, Michigan 49659

For Visa or MasterCard orders, you may fax the form to 231-587-8065