08/18/2021
****POSTPONED****
LEE COUNTY STRUTTERS
EVENT REGISTRATION FORM
SATURDAY,OCTOBER 2
***REGISTRATION DUE BY SEPTEMBER 3, 2021***
Open to youth age 5-17, Please complete IN FULL
Name:
Address: ________________________________________________________________________________
City, State and Zip: _______________________________________________________________________
Date of Birth: ________________________ Age: _________ Emergency Phone: _____________________
Email: _________________________________________________________________________________
Release of Liability & Photo Release
As the parent or legal guardian of the child listed above, I certify that said child has my permission to attend and participate in all activities on October 3, 2021 sponsored by the Lee County Strutters of the NWTF. By signing this form, I hereby waive and release all other participants, the host, sponsors and all other officials or parties involved in the event from all claims and or damage incurred in connection with this event. I also herby grant the sponsors and the co-sponsors the unconditional right to use the name, voice and photographic likeness of the above said child, in connection with any of the articles, press releases and audio, video productions.
______________________________________ ____________________________________ ______________
Signature of Parent/Legal Guardian Printed Name Date
THERE IS NO REGISTRATION FEE THIS YEAR!! Checks made payable to Lee County Strutters. Each child will receive one free event T-shirt and become a member of the NWTF JAKES with a one year subscription to the JAKES magazine. Please select T-shirt size below. Any additional shirts are $10.00 each.
T-Shirt Size:
Total # needed (1 free):
Youth Medium
Youth Large
Adult Small
Adult Medium
Adult Large
Adult XLarge
Adult XXLarge
TOTAL $:
You may mail registrations to:
Lee County Stutters
PO Box 293 Jonesville, VA 24263
OR drop off registration forms at the following locations:
Lee Farmers Co-Op, Liberty Sport and Pawn, and Smokin' Guns in Pennington Gap
Any questions, please call 276-870-9593
Lee County Strutters