'THE GOLD RUSH MOTHER LODE’ a four day adventure challenge September 8th-11th Official Entry Form 2011

MAIL TO: Team Karma, 1521 De Ve Ave, Modesto, CA 95350. Phone: (209)-575-3041

Team Name: __________________________________

MEMBERS:

1. Name: E-mail:  _________________________________________________  

Address: City: State: Zip:

Age Race Day: M F Shirt Size: (S,M,L,XL,XXL) Phone:

2. Name: E-mail: _________________________________________________

Address: City: State: Zip:

Age Race Day: M F Shirt Size: (S,M,L,XL,XXL)

3. Name: E-mail:  _________________________________________________

Address: City: State: Zip:

Age Race Day: M F Shirt Size: (S,M,L,XL,XXL)

4. Name: E-mail:  _________________________________________________  

Address: City: State: Zip:

Age Race Day: M F Shirt Size: (S,M,L,XL,XXL)

ENTRY FEE: $2245 four person team. $561/person, ($449 under 25).  $

LATE ENTRY: After July 1st 2011, additional  $180.00 per team) $

TOTAL FEE SUBMITTED (checks payable to ‘Adrian Crane Adventures’. or Paypal to : KarmaEntry@Pacbell.net . ) $

RACE IS LIMITED TO 45 TEAMS

Liability waiver will be signed at check in