Riders Name:

                                                Passenger / Spouse :

                                                Street Address:

                                                City:

                                                State/Prov.: Zip/Postal Code:

                                                Telephone:

                                                Email Address:

                                               Banquet Dinner:  Single $40.00    With Passenger $60.00

                                               Without Banquet Dinner:  Single $20.00    With Passenger $30.00

                                               Extra Dinners Tickets $20.00 ea. Total Amount

                                               Children's Dinner (Chicken Strips) $8.00 ea. Total Amount

                                               Harley Drawing: Number of Donations   Total Amount

                                                
                                                Total Charge Amount to Credit Card:  
                                               
                                               Name on Card:

                                               Credit Card Number:

                                               Exp. Date: Zip/Postal Code for Card:

                               How did you hear about the SCRC National St. Jude Rally: