Pre-Registration Form

Please print and mail with a check made to: West Coasters PATHA

Must be Postmarked no later that April 7th, 2010

You will be entered into a drawing for a Great Prize if You Register Early

 

                   

 

 

 

 

 

 

 

 

 

 

 

Total Amount Enclosed __________________

 

MAKE CHECK PAYABLE TO: West Coast PATHA

Mail to: West Coast PATHA Attn: Ralph Crowther

26722 Valpariso Dr. Mission Viejo, Ca. 92691

 

Name: _________________________________ Phone: __________________________

Address: ________________________________________________________________

City: __________________________________State: __________ Zip: ______________

Club Affiliation: __________________________________________________________

I acknowledge by my signature below that I will not hold the West Coast Prospectors and Treasure Hunters Association, or any member there of, responsible for the injuries or accidents I may incur while participating in any of the events conducted during Rendezvous 2010

Signature _______________________________________________ Date _____________