Chattanooga Dam Triathlon Application

Official Entry Form
Chattanooga's Dam Triathlon
Sunday June 27, 2004

Make checks payable to: Chattanooga Track Club
Mail to: Chattanooga's Dam Triathlon
303 Amhurst Ave.
Chattanooga, TN 37411

Official Use

Check Applicable Boxes
Age Group	$55	+ $ __________
Clydesdale or Athena (circle one)	$55	+ $ __________
Relay Team Member	$120	+ $ __________
USAT Single Event license fee (if not annual member)	add $9.00	+ $ __________
Chattanooga Track Club Members (pre-registered only)	deduct $5.00	- $ __________
		Total $ ________

Entry Fees are Non-Refundable
               Relay Team members must complete separate entry forms listing which event each team member will participate in and submit together with full payment.
               This is an USAT Sancioned Event - All entrants are required to have an annual USAT license or purchase a one day license for $9. Only one member of a relay team needs to have a USAT license. Annual licenses may be purchased for $30. Annual members must present their license at packet pick-up or purchase a one day license for $9. No Exceptions.
                Important: You are required to read and sign an Acknowledgment Waiver and Release from Liability Form and TVA Waiver at packet pick-up. Participants under 18 years old must have a parent or guardian sign the waivers. USAT now requires that entrants bring a photo id with them when they are registering.

Please Print Clearly
First Name _______________________________ Last Name _____________________________

Age (on 6/27/04) _____ Date of Birth ___________ Sex _____ T-Shirt Size S M L XL XXL

Address ________________________________________________________________________

City/State/Zip _______________________________ Email Address _________________________

Daytime Phone ( ) _____________________ Evening Phone ( ) _____________________

USAT License Number ________________________ ChampionChip Number _________________

Please list: _______________________________________________________________________

Emergency Contact: ______________________________ Phone: ( ) _____________________