Vehicle Registration Form

_  Motorcycle                _  Car/Truck

_  Registration: $15.00

_  Additional Participant $5.00

  _  Show only    _  Run only    _  Both

Total Amount Enclosed: $______________

Driver Name:                                                                                           

Address:                                                                                                        

City:                                                                     

State:                              ZIP:                              

Email:                                                                   

Vehicle Make: ________________________

Model: ______________________________

Year : _______________________________

Group Affiliation: _____________________

Pay with:

_ Check (Payable to: Ride & Rally For a Cure)

_ Cash

I would like my registration money to go to:

                          (check one)

_   Alzheimer’s Association

_   American Cancer Society

_   Pancreatic Cancer Action Network

_   Juvenile Diabetes Research

     Foundation

_   All of the above (divided equally)

RELEASE AND WAIVER OF

 LIABILITY

I________________________________________,          

                  (Print name of participant)

the undersigned hereby releases, waives, discharges and covenants not to sue the sponsors.,  the American Cancer Society, PanCAN, JDRF, Alzheimer’s Association, or any member of the organizing committee for the Ride & Rally for a Cure, or any of its affiliates, members of its Board of Directors, employees, agents, contractors, sponsors, vendors, or volunteers, and all other personnel whether volunteers or paid staff, for any and all liability, claims, demands, damages, causes of action, losses, or expenses (including attorneys fees and expenses) to the undersigned or to the minor child, on account of physical, mental, or emotional injury, or death of the person or to the property of. The undersigned hereby assumes full responsibility for and risk of bodily injury to or death due to the negligence or gross negligence of staff and also releases the above named organizations, from any and all liability for the intentional or criminal acts of its volunteers, agents, and/or employees while you participate in or travel to and from the Event.

The undersigned further expressly agrees that the foregoing release and waiver is intended to be as broad and inclusive as is permitted by the law, and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. The undersigned has read and voluntarily signs the Release and Waiver of Liability, and further agrees that no oral representations, statement or inducement apart from the foregoing have been made, and that this Agreement may only be modified by a written document signed by the undersigned and a duly authorized representative of Ride & Rally For A Cure.

I also accept absolute responsibility for my passengers.

Driver’s Signature _____________________________ 

Date: __________________

Passenger Name(s) & Age (if a minor):

_____________________________________________

_____________________________________________

_____________________________________________

_____________________________________________