SCRC Registration Form.

14th Annual Southern Cruisers , Cruisin for a Cure National Convention
August 30th thru September 2nd, 2012
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PRE-REGISTRATION FEE: Rider/Single $30.00
INCLUDES:
Special Event Patch show above ( PRE-REGISTRATION ONLY )
Dice Run, St. Jude Patch/Pin (first time), 2012 St. Jude Pin Rocker, 2012 St. Jude Patch Rocker, Saturday Night Awards & Auction, Saturday Dinner/Comedy Show
Passenger/Spouse (with or without bike) -$25.00 Includes: Same as above

Comedian John Morgan
http://www.johnmorgancomedy.com/

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REGISTRATION FEE at the Table: Rider/Single $35.00
INCLUDES:
Dice Run, St. Jude Patch/Pin (first time), 2012 St. Jude Pin Rocker, 2012 St. Jude Patch Rocker, Saturday Night Awards & Auction, Saturday Dinner/Comedy Show
Passenger/Spouse - $30.00 Includes: Same as above

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Main St. Jude Patch will be sold at the Event: Extra Main Patch or Pin $6.00 ea, Extra Patch or Pin 2012 Rocker $3.00 ea
Dice Run Sheet $10.00 ea; Saturday Night Dinner/ Comedy Show $17.00 ea.
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Secure On-Line Registration by Visa or Master Card Only
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Personal Registration

Please fill out this form and print
Mail To:
James Prescott
13128 Hwy 5 South
Norfork, Arkansas 72658

SCRC Cruisin for a Cure / St. Jude Registration Form

Rider/Single
First Name	Last Name

Passenger/Spouse (with or without bike) First Name	Last Name

SCRC Chapter Name
Street Address

City	State/ Prov	Zip/Postal Code

Home Telephone	Work or Cell Telephone

Email Address	Other source of contact


	SCRC Officer
	Yes No

Please select the options below.
Pre-registration Only
Single Rider - $30.00    With Passenger $55.00
                                                                                                      Total Amount

Total Amount of Check or Money Order

Will you be attending the SCRC Awards & Auction on Saturday Night, or the SCRC Dice Run on Saturday.
Awards Dice Run	Please Make Checks payable to Crusin For A Cure, with the Southern Cruisers Name in the "FOR" section of the check.
ePlease Read WAIVER OF LIABILITY Click Here Waivers are signed at the Eventre

Please send Check or Money Order to

James Prescott
13128 Hwy 5 South
Norfork, Arkansas 72658

Name or Email address of person who referred you
(please leave blank if no one referred you)

All Information is kept Private and not giving out to any other parties.