2008
GVFD POKER RUN PRE-REGISTRATION FORM
This is a Release and Indemnity Agreement. Read
it Before Signing!
I hereby give up all my rights to sue or make
claim for damages due to negligence or any other reason what-so-ever
against the Gaylordsville Volunteer Fire Department (GVFD) and
all other persons, participants or other organizations conducting
or connected with this event for injury to property or person
I may suffer, including, but not limited to, crippling injury
or death, while participating in this event and while on the premises.
I know the risks of danger to myself and my property
while preparing for and participating in the event and while upon
the event premises and, relying upon my own judgment and ability
I assume all such risks of loss and hereby agree to reimburse
all costs to those persons or organizations connected with this
event for damages incurred as a result of my negligence.
The rights to any photo's taken of me and/or
my personal property during this event belong to the GVFD and
may be used for future promotional purposes.
INSTRUCTIONS:
Print out this form on your computer, fill out the section below
and mail the entire page along with your payment to the GVFD.
- PLEASE PRINT
LEGIBLY AND
SIGN BELOW:
-
-
- Driver's Name___________________________________________________
Last . First
- Passenger's Name________________________________________________
Last . First
- Address_______________________________________________________
-
- City_____________________________
_____________________________
-
- State__________________________________________
Zip____________
-
- Telephone # (_______) ___________________________________________
-
- Email address:__________________________________________________
-
- Driver's Signature________________________________________________
-
-
- Driver T-Shirt Size_______ (Free with pre-registration while
supply and sizes last)
-
-
- Passenger's Signature (or Parent if Minor)_________________________________
- Age of Minor:______
-
- Driver $35 / Passenger $25 Total
Enclosed: _______________________
-
- Make all checks payable to the : GVFD and mail to:
- GVFD Poker Run
P.O. Box 230
Gaylordsville, CT 06755
- All proceeds benefit the Gaylordsville Volunteer
Fire Department
- ©2008 Gaylordsville Volunteer
Fire Department