Registration Form for 2011 SCF Clewiston, FL 200k BREVET

Last Name: ______________________________ First Name: ___________________________

Address: ________________________________________________________________________

________________________________________________________________________________

City: _______________________________ State: _____________ Zip: _________________

Telephone: __________________________ E-mail: ____________________________________

RUSA# (required only if you are a member)____________

Any health concerns: _______________________________________________________________

________________________________________________________________________________

Emergency Contact: Name: __________________________ Tel: ___________________________

Please send $20 as a check payable to John Preston.

Send registration and check to: John Preston

6751 NW 9^th St

Plantation, FL 33317

For more information, call John Preston @ 954-444-0910 or e-mail john@johnandjuliet.com

website: http://www.johnandjuliet.com/RUSA/SouthFlorida2010

Randonneurs USA website: http://www.rusa.org