Registration Form for 2012 SCF Big Cypress BREVET

Last Name: ______________________________        First Name: ___________________________

Address: ________________________________________________________________________

________________________________________________________________________________

City: _______________________________      State: _____________        Zip: _________________

Telephone: __________________________     E-mail: ____________________________________

RUSA# (required only if you are a member)____________

Any health concerns: _______________________________________________________________

________________________________________________________________________________

Emergency Contact: Name: __________________________  Tel: ___________________________

Please send  $20 as a check payable to John Preston.

Send registration and check to:                                    John Preston

6751 NW 9^th St

Plantation, FL 33317

For more information, call John Preston @ 954-444-0910 or e-mail john@johnandjuliet.com

website: http://www.johnandjuliet.com/RUSA/SouthFlorida2012

Randonneurs USA website: http://www.rusa.org