Event Date: Sunday January 22, 2012
Event Cost: $20 (by Jan 15, 2012)
Event Cost: $25 (
on or after Jan 16, 2012
)
Registration Deadline Jan 18 by 9:30 am
if you have questions please call
Susie at (316) 529-2677.
Name
Address
City/Zip
Phone Home Phone Work
Email
Female
Male
Date of Birth (Month/Day/Year)
Shirt Size
S
M
L
XL
Estimated 500 yd swim time
(min)
(sec)
Waiver for Participant
In consideration of your accepting this entry, I hereby, for myself, and child, my heirs, executors and administrators, waive and release any and all rights and claims for damages I or my child may have against the Derby Recreation Commission, City of Derby or USD 260, and its representatives, successors and assigns for any and all injuries suffered by myself or my child at any activity sponsored by these groups. Parent or Legal Guardian must check for any child under 18.
agree
disagree
Payment method
Mastercard
Visa
Credit Card #
Credit card Exp. Date
