JUGGLING WORLD RECORD CLAIM FORM

Please print this page and send it in with your video.  (return home)

Record holder's Full Name: _________________________________________________________________  

Record holder's address:___________________________________________________________________

______________________________________________________________________________________

Record holder's email:_____________________________________________________________________

web address:__________________________________________  phone: ___________________________

Date/Time & Location of World Record:   ______________________________________________________

______________________________________________________________________________________

object specs (example:  club type, size, wt. etc):___________________________________________________

PLEASE INCLUDE A PHOTO OF THE RECORD BREAKER(S) TO BE INCLUDED IN THE BOOK.  (If a photo is not included, one may be taken from the actual video footage to be included in the book.)

Do we have permission to put a clip or all of your record on DVD if a DVD is included with this edition of the Juggling World Record Book?   (circle one)  Yes   No

State what the claimed world record is in the space below:

Witness' name:_________________________  Witness' phone: ___________________

Witness' email:__________________________________________ (add other witnesses on back)

Add any other comments about your record or any other interesting or funny facts about jugglers or juggling:

We thank you for taking the time to juggle!  The Juggling World Record Book is here to promote juggling and to promote you--the record breakers in what we consider the world's greatest sport!