13th Annual Mullet Man Triathlon
Saturday, April 18, 2009 ˇ 7:30 a.m.

Please fill out form by typing in responses and then print.

Individual Registration Relay Registration
Each member must fill out a separate
application and staple together.
$100.00 Charity Slot
 		  
Individual Athena Clydesdale Super Clydesdale Fat Tire First Timer Team Relay
First Name Last Name
MaleFemale Age (on Race Day): Birth Date:MMDDYY
Shirt Size: If none stated, large will be given. Small Medium Large X-Large XX-Large
Mailing Address:  Apt. or Unit #: 
City:  State:  Zip Code: 
E-Mail:  Daytime Phone Number --
Team Type: Male     Female     Coed Relay Leg: Team Name:

Release: In signing this release for myself or for the named entrant (if the entrant is under the age of 18), I acknowledge that I understand the intent hereof; and hereby agree to and will absolve and hold harmless the Flora-BamaŽ and their officers, directors and members respectively, and any other parties connected with this event in any way whatsoever, singly and collectively, from and against any blame or liability for any injury as a result in participation in this annual event or activities associated therewith. I also hereby consent and permit emergency treatment in the event of injury or illness. I shall abide by traffic laws and regulations and practice courtesy and safety. I agree to affix and display the registration number at all times. I agree to obey traffic rules and stay to the right of the road when and where possible. I agree to wear an ANSI or Snell approved helmet at all times while riding. Drug tests can and will be given. Any entrant (if asked) may not refuse a drug test. I have read and understand the above.
THIS FORM WILL NOT BE HONORED IF NOT SIGNED.

__________________________________________________ ___________________
Signature (Parent or Guardian's Signature if under 18 years of age) Date

Office Use Only

Check # ________

Amount $ ________

Received: ________


Mail Application to:
Flora-BamaŽ
17401 Perdido Key Drive
Pensacola, FL  32507


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