Défi de L'Île de Montréal

128 km on inline skates

FAMILY NAME:__________________________ FIRST NAME:_______________________

ADDRESS:_________________________________________________________________

CITY:_________________________________ PROV/STATE:_______________________

COUNTRY:______________________________ POSTAL CODE:______________________

DATE OF BIRTH:________________________

TEL:__________________________________ CELL:_____________________________

EMAIL:___________________________________________________________________ 

T-SHIRT SIZE:_____(Medium) _____(Large) _____(X-large)


SIGNATURE:_______________________________________________________________
(MUST be signed by you, or by your parent/guardian if you are under 18.)
"I hereby for myself, my heirs, executors or anyone else who might claim 
on my behalf, covenant not to sue or to claim damages against the Défi de 
L'Île de Montréal or any of its organizers or sponsors."


REGISTRATION: _____$55.00 (before October 1, 2010)
              _____$60.00 (after October 1, or 4:30-5:45 am on race day)