PRINT, FILL OUT, ENCLOSE $ 40.00 CHECK AND SEND TO:

AL DeLeon,   601 E OGDEN AVE #508   MILWAUKEE WI   53202

By my signature below, I release the Triwisconsin triathlon team, its officer, directors, agents, sponsors and representatives from any liability, damages, claims or causes of action which may arise in the future participation in any event which may be affiliated with the team

Signed __________________________________    date:______________________

Member:________________________________

Email Address__________________________________

Home Address:______________________________________

IN case of emergency phone number and contact: _____________________________