Midwest Regional Air Pistol

Team – International Air Pistol Registration

Coach Name *

Coach Phone *

Coach Email *

Number of Teams Registering *

Team One Name *

Team One Residency *

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

#1 Athlete Name - Team One *

First

Last

#1 Athlete Address - Team One *

Address Line 1

City

State

Zip Code

#1 Athlete Email - Team One *

Athlete #1 Phone - Team One *

Athlete #1 Date of Birth - Team One *

Athlete #1 CMP Number - Team One *

Athlete #1 Relay Selection - Team One *

#2 Athlete Name - Team One *

First

Last

#2 Athlete Address - Team One *

Address Line 1

City

State

Zip Code

#2 Athlete Email - Team One *

Athlete #2 Phone - Team One *

Athlete #2 Date of Birth - Team One *

Athlete #2 CMP Number - Team One *

Athlete #2 Relay Selection - Team One *

#3 Athlete Name - Team One *

First

Last

#3 Athlete Address - Team One *

Address Line 1

City

State

Zip Code

#3 Athlete Email - Team One *

Athlete #3 Phone - Team One *

Athlete #3 Date of Birth - Team One *

Athlete #3 CMP Number - Team One *

Athlete #3 Relay Selection - Team One *

#4 Athlete Name - Team One *

First

Last

#4 Athlete Address - Team One *

Address Line 1

City

State

Zip Code

#4 Athlete Email - Team One *

Athlete #4 Phone - Team One *

Athlete #4 Date of Birth - Team One *

Athlete #4 CMP Number - Team One *

Athlete #4 Relay Selection - Team One *

Total

$ 0.00

Authorize.Net *

Card Number

Expiration

Security Code