Wild West Clinic 
Please fill out the following Application Form, Print it out and Mail
to the address listed under Mailing Information
Applicant Information
First Name
 Last Name
 Applicant Title (if applicable)
Address Line 1
 Address Line 2
  
City
 State
 Zip Code
Phone Number
 Age
 Applicant E-Mail
Coach/Parent Information Check this Box if Coach/Parent's Address/Phone Number is the same as Applicant's Address/Phone Number
First Name
 Last Name
 Coach/Parent Title (if applicable)
Address Line 1
 Address Line 2
  
City
 State
 Zip Code
Phone Number
 Coach/Parent E-Mail
Payment Information
Number of Contestants - x $150.00
Number of Others - x $60.00
Total Amount Enclosed -                 $

Comments (Example--I  need a special diet of ....)

Mailing Information
 Please include check or money order payable to Miss Rodeo Nebraska Association, Inc.

Please mail to:   Miss Rodeo Nebraska Association, Inc.
Kathy Moorhead, 2004 W. 5th Street, Ogallala, NE 69153

308-284-2957
clinic@missrodeonebraska.org 


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