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Registration Form

Group or Organization Name: _________________________________________________

Contact Person: ______________________________________________________________

Mailing address: _____________________________________________________________

Email: __________________________________ Phone #:_________________________

I understand and agree to the rules provided:________________________________________


Participants signature
Registration fee is $10.00
Please make all checks payable to Clearwater PowerUps
Entry due date is Wednesday, January 22nd, by 6:00 pm
For more information please email cwpowerups@gmail.com or call Micca Shipman at 316641-2876, Heather Cotton at 316-617-4183, or Pamela Riggs at 620-545-5158

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