2009 CFPS CHANTRY CHINOOK CLASSIC REGISTRATION FORM

(Tickets mailed on receipt of this form when mailed to the address below)

Derby Ticket Costs: Single $25.00  Family $55.00

PLEASE PRINT CLEARLY AND CHECK ALL APPLICABLE CATEGORIES

Name:___________________________ 17 or under___60 or 

Over___Male___Female___

Address:______________________________________________________

Town:______________________________Postal code:_______________

Province:____________________Phone (________)__________________

TO BE COMPLETED BY FAMILY ENTRIES ONLY

Spouses Name:_________________ 17 or Under___ 60 or Over 

___Male___Female___

CHILDREN MUST BE 17 OR UNDER!

1st Child’s Name:______________________age___ Male___ Female___

2nd Child's Name:_____________________ age___ Male___ Female___

3rd Child's Name:______________________age___ Male___ Female___

4th Child's Name:______________________age____Male___ Female___

I have read, and agree to abide by the rules of the
CFPS CHANTRY CHINOOK CLASSIC DERBY COMMITTEE.



Signature________________________________________________________


Make Cheques Payable To: CFPS Chantry Chinook Classic

Mail to: Bill Boyd, R. R. # 1, Ripley, Ontario N0G 2R0

Ticket orders received after July 14 are held for pickup at the Kincardine Weigh Station.