Walkertown Civic Club

3^rd Annual Poker Run

Registration Form

Saturday May 31^st 2008

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

Walkertown Shopping Center – beside Wings N Things

 

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

             __________________________________________________________________________________

 

                  ___ $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

             ________________________________________________________________

Make checks payable to Walkertown Civic Club and mail to

P.O. Box 772, Walkertown, NC 27360

 

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 and 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:_____________