Midwest regional - The X Count

Team – International Air Registration

Team Name

Coach Name

Coach Phone

Coach Email *

Residency

Indiana Team (All Members are Indiana Residents)
National Team (Local Club - Non Indiana Team but all members live within 90 miles of the registering club)
National Team (Open Club - No restrictions on distance from the club)

#1 Athlete Name *

First

Last

#1 Athlete Address

Address Line 1

City

State

Zip Code

#1 Athlete Email *

Athlete #1 Phone

Athlete #1 Date of Birth

Athlete #1 CMP Number

#2 Athlete Name *

First

Last

#2 Athlete Address

Address Line 1

City

State

Zip Code

#2 Athlete Email *

Athlete #2 Phone

Athlete #2 Date of Birth

Athlete #2 CMP Number

#3 Athlete Name *

First

Last

#3 Athlete Address

Address Line 1

City

State

Zip Code

#3 Athlete Email *

Athlete #3 Phone

Athlete #3 Date of Birth

Athlete #3 CMP Number

#4 Athlete Name *

First

Last

#4 Athlete Address

Address Line 1

City

State

Zip Code

#4 Athlete Email *

Athlete #4 Phone

Athlete #4 Date of Birth

Athlete #4 CMP Number

Relay Selection - International Air Rifle

Total

$ 0.00

Authorize.Net *

Card Number

Expiration

Security Code