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Salt Valley District Pinewood Derby Individual and Pack Registration Form Saturday, March 5, 2011 St. Mark’s United Methodist Church 8550 Pioneer Boulevard, Lincoln, Nebraska Pack leaders or one designated person per pack is responsible for registering cub scouts in the District Derby. When registering your pack, please include the List of Competitors Form with individual entry details (page 2). Discounted registrations accepted until February 6. All other entries are due by Monday, February 28, 2011. Step 1: Person Submitting Registration Name: ___________________________________________ Address: ___________________________________________ City/ST/Zip: ___________________________________________ Phone: ___________________________________________ Email: ___________________________________________ Unit and Number: _______________ Scouting Position ______________________________ Check here if you are a District or Council Scouter not registered with a unit. You may register 2 people. Step 2: Number of People Registering x entry fee* per person *Early Bird Price: $5 per entry good until Sunday, February 6th *Regular Price: $7 per entry after February 7th until Sunday, February 20st *Late Registration: $10 per entry after February 21st until Monday, February 28th NO REGISTRATIONS ACCEPTED after February 28th, 2011 Registration Level

Quantity

Salt Valley District Pinewood Derby Race Car Show Design Competition Outlaw Race

Each ($5,$7,$10)

x x x

Grand Total

Total

= = = $

Step 3: Registration Costs and Payment (please read the Cornhusker Council refund policy) Please attach personal or Pack check payable to Cornhusker Council BSA and send/deliver to the Cornhusker Council, P.O. Box 269, 600 S. 120th, Walton, NE 68461 or fax to 488-6072. REGISTRATION CLOSES at Monday 2/28/2011 @ 11:59PM. Step 4: Mandatory Check-in: Friday, March 4, 6:00pm - 9:00pm at St. Mark’s United Methodist Church-Family Life Center, 8550 Pioneers Blvd. (Send your car with a friend if you are unable to attend)

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List of Competitors Form Step 4: Provide the names of all people registering Pinewood Derby Race (Packs may enter up to 2 Scouts from each rank OR the 10 fastest racers (Please circle rank and print name legibly) 1. Tiger Wolf Bear Webelos1

Webelos2

Name: ________________________________

2. Tiger Wolf Bear Webelos1

Webelos2

Name: ________________________________

3. Tiger Wolf Bear Webelos1

Webelos2

Name: ________________________________

4. Tiger Wolf Bear Webelos1

Webelos2

Name: ________________________________

5. Tiger Wolf Bear Webelos1

Webelos2

Name: ________________________________

6. Tiger Wolf Bear Webelos1

Webelos2

Name: ________________________________

7. Tiger Wolf Bear Webelos1

Webelos2

Name: ________________________________

8. Tiger Wolf Bear Webelos1

Webelos2

Name: ________________________________

9. Tiger Wolf Bear Webelos1

Webelos2

Name: ________________________________

10. Tiger Wolf Bear Webelos1

Webelos2

Name: ________________________________

Car Show (Packs may enter up to 5 Scouts from any ranks--Scouts may NOT dual register for Race (Please circle rank and print name legibly) 1. Tiger Wolf Bear Webelos1

Webelos2

Name: ________________________________

2. Tiger Wolf Bear Webelos1

Webelos2

Name: ________________________________

3. Tiger Wolf Bear Webelos1

Webelos2

Name: ________________________________

4. Tiger Wolf Bear Webelos1

Webelos2

Name: ________________________________

5. Tiger Wolf Bear Webelos1

Webelos2

Name: ________________________________

Outlaw Race (The Outlaw race is open to any Cub Scout or Boy Scout family member; only the first 36 registrants will be accepted district-wide for this race) Registrant #1

___________________________________________

Registrant #2

___________________________________________

Registrant #3

___________________________________________

Please attach List of Competitors to Pack Registration Form and send/deliver to the Cornhusker Council, P.O. Box 269, 600 S. 120th, Walton, NE 68461. REGISTRATION CLOSES Monday 2/28/11 @ 11:59PM. 2|Page


PWD2011_RegistrationForm