Jim Hogan Fun Run -

August 13-14, 2011

NAME __________________________________________     HOME PHONE __________________

ADDRESS _______________________________________     WORK PHONE __________________

CITY _______________________________________     STATE ___________     ZIP ____________

E-MAIL ____________________________________________________________________

                                                                       
   ~  REGISTRATION ~

ADMISSION.  Donation of $20.00 each and/or $10.00 per child under 12.
   HOW MANY?   Adults_______  Children under 12_______



                                                          
     ~ EMERGENCY CONTACT INFORMATION ~
NAME _______________________________________     PHONE ___________________________

MOTORCYCLE BRAND, YEAR, COLOR _________________________________________________

MOTORCYCLE REGISTERED IN WHAT STATE _________  LICENSE #________________________

NOTE:  All minors traveling with someone other than a parent or legal guardian, MUST have a signed,
notarized statement of temporary guardianship from their parents or guardian.  This is a MANDATORY
provision of our insurance.

FROM WHAT SOURCE DID YOU HEAR ABOUT  The Jim Hogan Fun Run ?


Magazine, which one _________________________ Club, which one __________________________
Advertisement/Website, which one ____________________ Friend or other source________________

Please make check payable to "Ely Lions" and mail to:

Jack Eudy
1091 Alcohol Rd.
Wrenshall, MN 55797

(218) 590-6806


For credit cards (Master Card & Visa, no American Express), include card type, number, exp date, amount to be charged, and signature.

Card type ________ Card number ____________________________ Exp date _________ 
Amount ____________ Signature ____________________________________________