Checkers AC Membership Application

WHICH RACE/EVENT? DATE DISTANCE CAPACITY ENTRY FEE
Full Time Student - 1 year membership -- -- -- $25.00
Individual - 1 year membership -- -- -- $35.00
Individual - 2 year membership -- -- -- $60.00
Individual - 3 year membership -- -- -- $85.00
Married Couple/Domestic Partnership - 1 year membership -- -- -- $45.00
Married Couple/Domestic Partnership - 2 year membership -- -- -- $80.00
Married Couple/Domestic Partnership - 3 year membership -- -- -- $115.00
Family - 1 year membership -- -- -- $50.00
Family - 2 year membership -- -- -- $90.00
Family - 3 year membership -- -- -- $130.00

***NOTE***
Your credit card statement will reflect a charge from:
Score This!!!, Inc. Event Registrations
the provider of online registration services for this event.
Online Payment Service

 
First name
Last name
Gender
Street address

City
State/Province
Zip
Email
Phone
Birthdate
Country
 
Waiver
 I agree       Initials of athlete over 18 years of age or parent/legal guardian of minor under 18 years of age or legal guardian of incapacitated and/or mentally challenged person: