Post on 17-Oct-2020
transcript
Registration Form
Interstate Credit Union Poker Run
Name
Address
Phone
T-Shirt Size: S M L XL XXL
Entry Fee $20.00 Paid: YES NO Amount: $_______
Additional Hand $5.00 Paid: YES NO Amount: $_______ Hands______
Additional Riders $5.00 Paid: YES NO Amount: $_______
Additional Rider Name
Waiver Signed: YES NO
(by all riders)
Signature Date
Signature of parent or guardian if under 18 years of age. Date
ACKNOWLEDGEMENT OF RISK AND WAIVER OF LIABILITY
In consideration of my participation in the Interstate Credit Union Poker Run, I acknowledge and
accept the risks, dangers and hazards associated with the Interstate Credit Union Poker Run
which may include, but are not limited to, road conditions, weather conditions, mechanical
failure, my failure to drive safely or within the limits of my own ability, and the negligence of
other motorcycle or motor vehicle drivers. I hereby waive all rights to sue or make any claims for
injuries or damages due to negligence or for any other reason whatsoever, against Interstate
Credit Union and any and all individuals, committees, corporations or other entities in any
capacity associated with the Interstate Credit Union Poker Run, (hereinafter Releasees), for injury
to person or damage to property that I may suffer, including crippling injury or death while
participating in any event or activity associated with the Interstate Credit Union Poker Run and
while upon the premises of any of the Releasees. I know the risks of danger to myself, my minor
child (if present), and my property while participating in the Interstate Credit Union Poker Run
and surrounding events. I do for myself, my heirs, next of kin, executors, administrators,
successors, assignees, and representatives hereby release and waive all rights and claims for
damages, losses or injuries incurred by me at the Interstate Credit Union Poker Run or as a result
of the Interstate Credit Union Poker Run.
I CONFIRM THAT I AM AT LEAST THE AGE OF 18 YEARS AND THAT I HAVE READ
AND UNDERSTOOD THIS AGREEMENT PRIOR TO SIGNING IT, AND I AM AWARE
THAT BY SIGNING THIS AGREEMENT I AM WAIVING CERTAIN LEGAL RIGHTS
WHICH I OR MY HEIRS, NEXT OF KIN, EXECUTORS, ADMINISTRATORS,
SUCCESSORS, ASSIGNEES AND REPRESENTATIVES MAY HAVE AGAINST THE
RELEASEES.
I acknowledge that I have insurance for bodily injury and property damages as well as medical
expense coverage for my passenger and myself.
PARTICIPANT SIGNATURE
________________________________________ __________________________
Signature Date
________________________________________ __________________________
Signature for minor Date
PASSENGER SIGNATURE
________________________________________ __________________________
Signature Date