RALLY REGISTRATION FORM

Last Name _____________________________ First Name_________________________

Address _________________________________________________________________

City ______________________________ State __________ Zip Code ______________

Phone _______________________ Division ______ Club ________________________

Club office currently held ____________________________________________________

Circle One:

Key Clubber      Kiwanian      Faculty      Circle K      Guest

I have read the accompaning code of conduct, completed the medical
questionaire and have my parents' permission to attend this rally:

___________________________________________            _________________
Signature of Parent or Guardian                                          Date

Return registration form, medical questionaire and code-of-conduct form to:

                                                      [Rally Co-Ordinator]