Application

Official Entry Form
Chattanooga's Dam Triathlon
Sunday June 22, 2003

Make checks payable to: Chattanooga Track Club
Mail to: Chattanooga's Dam Triathlon
1014 Whispering Oak Lane
Chattanooga, TN 37421
Pre-registration by mail only through June 15, 2003.

Official Use

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Check Applicable Boxes	By 6/15	On 6/22
Age Group	$50	$70	+ $ __________
Clydesdale or Athena (circle one)	$50	$70	+ $ __________
Relay Team Member	$40 each event	$70 each event	+ $ __________
USAT Single Event license fee (if not annual member)	add $7.00		+ $ __________
Chattanooga Track Club Members (pre-registered only)	deduct $5.00		- $ __________
			Total $ ________

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Entry Fees are Non-Refundable
               Relay Team members must complete separate entry forms and submit together with full payment.
               This is an USAT Sancioned Event - All entrants (including each relay team member) are required to have an annual USAT license or purchase a one day license for $7. Annual licenses may be purchased for $25. Annual members must present their license at packet pick-up or purchase a one day license for $7. 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.

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Please Print Clearly
First Name _______________________________ Last Name _____________________________

Age (on 6/22/03) _____ 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: ( ) _____________________