Walkertown Civic Club



Poker Run Registration

 

Walkertown Civic Club

4th Annual Poker Run

Registration Form

Saturday June 5, 2008

 Registration begins at: 8:30am – Ride begins at 10:00am

Walkertown Elementary School Parking Lot

 

For more information contact: Stephen Amos – (336) 462-2024

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               __ $20.00 for Driver (includes T-Shirt)

            __ $10.00 for Passenger or Extra Hand.

            __ $10.00 Bike Show

            __ $5.00 Bike Games

            __ $30.00 for combination Driver, Bike Show and Bike Games

______ ________________________________________________________________Pay by

Check

Make checks payable to Walkertown Civic Club and mail to

P.O. Box 772, Walkertown, NC 27360 or email form to walkertowncivicclub@walkertowncivicclub.org and submit payment using PayPal.      

 

 

 

 

 

Name: ____________________________________________________________________________________

 

Address: _________________________________________ City: _________________State: ___ Zip: _______

 

Telephone:_____________________________Email:______________________________________________

 

Rider T-shirt Size: __ S __ M __ L __ XL __ XXL __ XXXL __ 

Passenger T-shirt Size: __ S __ M __ L __ XL __ XXL __ XXXL __ 

MOTORCYCLE WAIVER AND RELEASE FORM

In signing this document, I represent that I am fully knowledgeable of the danger and hazards associated with riding motorcycles. I certify that I am duly licensed and competent to operate a motorcycle in a safe manner, and the vehicle is in a safe operating condition. I will be riding on public highways and am solely responsible to determine the speed and operational characteristics of my motorcycle while participating in the tour. I am licensed to operate a motorcycle and always carry motorcycle liability insurance as required by law. I hereby release and hold harmless, Walkertown Civic Club, Inc. and Star Touring & Riding Assoc, and any of their executives or members, against any and all claims, causes of action, or any other liability of any kind arising from my activity of touring by motorcycle.

I certify that I have no known physical or mental impairment that may affect my safety or the safety of the group, I understand that the choice of wearing a helmet or other protective gear is solely my own and that I am responsible for my compliance with all state laws, including those regarding helmets. I certify that I am not under the influence of any narcotic, alcohol or other drug that may impair my understanding or judgment ant that I will not at any time during the tour operate my motorcycle under the influence of any narcotic, alcohol or any drug.

Signature of Rider:_____________________________________________________ Date:________________

 

Signature of Passenger:__________________________________________________ Date:________________

 

Signature of Parent if Participant is Under 18:_________________________________ Date:_______________

 

 

 

 

 

 

 

 

 

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