Please print this form, fill it out, and then mail it to address below!

Date:  July 17th, 2010

Team Name (1st Side):

Division Entered:

Men's Club:

Men's Collegiate:

Jersey Colors:

Team Name (2nd Side):

Division Entered:

Men's Club:

Men's Collegiate:

Jersey Colors:

Tent & Water Package (1 canopy tent & 3 cases of water) = $ 100.00:

Yes:

No:

Contact Name:

Address:

Phone:

(H)

(W)

E-mail:

Entry Fee:

  ______  $ 150.00 per 1st Team  |  ______  $ 100.00 per Additional Team

  Total enclosed:  ____________  |  Entry Fee Deadline:  July 10th, 2010

Make Check Payable to:

  Ben Cybulski  |  NO CASH WILL BE ACCEPTED  |  Checks made out to SIU Rugby will not be honored

Mail your Registration Form and Check, by the10th of July, to:

Ben Cybulski, 513 South Ash - Apt. 2, Carbondale, IL 62901

Check #:

Date:

Amount:

Authorized by:

Questions:

  Contact Luke Mathews, 217-898-6455

If you need a receipt, other than your cancelled check, make a copy of the filled out form and use it as your receipt!