Blake Jones Derby ~ March 16, 2019 2019 Blake Jones Derby Pre-Registration Form Name* First Last Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email* Who is Registering?Today I am registering:*MyselfMore than just me (family/group)Adult registration Price: $20.00 Adult registration* Price: $20.00 Quantity: Child registration Price: $10.00 Quantity: Child registration prices for ages 11 and under.Other participant names and their emails*Participant NameParticipant Email List the names of participants you are paying registration for. These people will be sent a request to sign the waiver necessary for participation in the Derby. IF THE PARTICIPANT IS A CHILD, even if it is your child, please list the child's legal guardian's name and email so a separate waiver can be signed. Click the + symbol if you need to add another line/participant.Commemorative Blake Jones Tee ShirtsAdult 2019 Tee Shirts Price: $20.00 Quantity: Please list size(s) desiredS, M, L, XL, 2XL, 3XL State quantity of each size if ordering more than two.Children's 2019 Tee Shirts Price: $10.00 Quantity: Please list children's size(s) desired:Small, Medium, or Large State quantity of each size if ordering more than two.WaiverReleaseI hereby release the Bishop Area Chamber of Commerce and all participating sponsors of the derby form any loss of property, bodily injury, or loss of life that may occur in this derby. I also agree to follow all CADFW Regulations and Blake Jones Derby Rules. (If you are under the age of 18, a parent or guardian must sign.)Signature*PaymentBlake Jones is a “Rain or Shine” event - Sorry, no refunds.Total $0.00 Credit Card* American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20192020202120222023202420252026202720282029203020312032203320342035203620372038 Expiration Date Security Code Cardholder Name NameThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms. Print the 2019 registration form (PDF) Request a FREE Bishop Vacation Planner *protected content* Blog Posts by SeasonWinter Fall Spring Summer Year Round Search for:
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