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