Name                                                                                                                          .

Address                                                                                                                      .

City                                                    State                            Zip Code                     .

Home Phone                                                                                                              .

Emergency Contact                                                                                                    .

Emergency Contact Phone                                                                                      .

Email Address                                                                                                         .
 

Please check:

          U of M Student/Faculty/Staff ($125)                       Public over 18 years($135)
 

Amount of payment enclosed:  $                                          .
 

Make checks payable to:

    MICHIGAN ATHLETIC DEPARTMENT
 

Mail application and payment to:

    UNIVERSITY OF MICHIGAN ATHLETIC DEPARTMENT
    INDOOR TRACK BUILDING
    1000 S. STATE STREET
    ANN ARBOR, MI  48109-2201