Name of Event:

________________________________________

Date of Event:

____________________

Section:

____________________

Byes Requested for:

________________________________________

Name:

________________________________________

Address:

________________________________________

City / State / Zip:

________________________________________

Phone:

____________________

USCF # :

____________________

Rating:

____________________

USCF Expiration:

____________________

Entry Fee:

$

____________________

Memberships

USCF:

$

____________________

MACA Adult @ $12

$

____________________

MACA Junior @ $  6
under 18 years old

$

____________________

Total Enclosed:

$

____________________

Date of Birth for Juniors:  

____________________

Email Addresses:

Please print clearly

________________________________________

Make Checks payable to MACA and mail to:

Donna Alarie
21 Blueberry Lane
Rutland, MA  01543