Roundup Registration Form

June 22-25, 2016
Kansas City, MO

(Roundup participants should make their own Hotel reservations by May 20, 2016)

_____Adult(s) @ $150.00/person = __________

_____Student(s) (13 yrs to college) @ $130.00/person = __________

_____Children (5 yrs to 12) @ $85.00/person = __________

_____Children (4 and under) free

Name: _____________________________________________________________________

Address: ___________________________________________________________________

___________________________________________________________________________

Home Phone: (_____) ____________________ Cell Phone: (_____) ____________________

Email address: _______________________________________________________________

* Please print first and last names of all who will be attending so name tags can be made:

______________________________________________________________________________

_______Individual Adult @ $25/person =___________

_______Family (all persons living at the same address) @ $40/family = ___________

_______Senior (65 or over) @ $20/person = ___________

_______Junior (under 18) @ $10/person = ___________

Names on membership:

______________________________________________________________________________

Address:______________________________________________________________________

____________________________________________________________________________

Home Phone: (_____) ____________________ Cell Phone: (_____) ____________________

Email address: _______________________________________________________________

BLOG or Website URL: ________________________________________________________

Social Networks: ___________________________________________ (Facebook, Twitter, etc.)

Enclose a check payable to: Texas Jack Association for:

TOTAL = _______________

Please send completed forms and check to:

Rick Omohundro, Treasurer TJA PO Box 91 Salt Lick, KY 40371