Rollin on the River

Mississippi 2009 State Rally

May 8th - 10th

Pre - Registration

Registration cost for the State Rally will be $25.00 per person.  Registration price includes T-shirt, Rally Pin, Friday night dinner and all the fun you can have. Dice run hands purchased at Rally.

Note: T-shirt and Rally Pin guaranteed for first 200 registered. First come first serve thereafter.

All proceeds from the registration will go to St. Jude Children's Research Hospital. 

Please fill out this form, print it out.  Print out the Release and Waiver of Liability Agreement, fill it out and mail it along with your payment to the address listed below.  We look forward to seeing you.
Name:

Address

City, St. Zip

 Spouse/Guest

Email:

Phone

Chapter:

Roadname

 (please enter your chapter number)
I have read and agree to the terms of the Release and Waiver of Liability Agreement (click here to view).
Info: I will be staying at the host hotel: 

Click here for the hotel website. Group name Southern Cruisers, rate is $66.00 per night up to 2 people, additional $5.00 for extra people. We also get a free breakfast buffet and two free drinks of your choice each night.
Check if you are an Officer of SCRC?  What level? 

 

 Please select the number attending at $25.00 per person.

Rally pin for first 200 registered.
I am attending the dinner Friday night. 

Enter the total amount of your registration fee:  $ 
 

T-Shirt Ordering Info: (First 200 registered)

 

Pre-registrations MUST be received by April 1st. 2009 

after that you will have to register at the event AND MAY NOT BE GUARANTEED A T-SHIRT!!!
Small  T-Shirt ,  # of shirts
Medium    T-Shirt , # of shirts 
Large     T-Shirt , # of shirts  
X-Large   T-Shirt , # of shirts  
2-X T-Shirt , # of shirts  
 

Send payment, Waiver & Mississippi State Rally registration to:

Dan Jackson

45 Massey Rd.

Vicksburg, MS. 39180

  

MAKE CHECKS PAYABLE TO:

Dan Jackson

 

Place Your Comments Here:   (Shirt Quantity, size, etc.)