Name ___________________________________________________________

Mailing Address __________________________________________________

City______________________________State_______ Zip________________

Phone _______________ E-mail Address _____________________________

Age on 6/11/11___ Date of Birth___________USAT #__________Sex - M F

Shirt Size - circle one -  S    M    L    XL   (Late registrants not guaranteed a shirt) 

Triathlon/Duathlon Fees

Regular Price

$65  USAT member and military until 6/3/11 at midnight

$75 Non USAT member until 6/3/11 at midnight

Late

$85 everyone 6/2/11 thru race day

In consideration of the acceptance of my entry, I, for myself, my executors, administrators and assignees do hereby release and discharge MultiSport Maniacs, and all associated sponsors of all claims and damages, demands, actions whatsoever in any manner arising out of my participation in said athletic event. I attest and verify that I have full knowledge of the risks involved in this event and I am physically fit and sufficiently trained to participate in this event. I have fully read and understood the race application, rules and information whether on the web site or on the application and will abide by all the rules therein.

 Individual Signature _________________________________________
(Parent's if under18)

For more information call Chad - 717-991-9102 or e-mail: chad.krebs@multisportmaniacs.org 
                   
A portion of the proceeds will benefit the YMCA and Families of Deployed Soldiers