desert to the mountains fun run - Northwest Vintage Speedsters

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“Desert to the Mountains Fun Run” May 26th – 27th, 2007 Registration Form Registration cut-off date is May 1 st – $25.00 late registration fee after May 1st (Please sign waiver on reverse side of this registration form) Driver’s Name _____________________________ (As you would like your name tags printed) Mechanic’s Name_______________________ (As you would like your name tags printed) Address ___________________________________________________________________________ City _________________________________ State _________ Zip ___________________ Phone # _____________Cell: ________________ E-mail Address ___________________________ Car # *__________________ Year____________ Body Style ______________________________ Make of Speedster ___________ Registered Owner’s Name ________________________________ Color _____________________________ Other features: ___________________________________ Auto Insurance Company ________________________ Policy # _____________________________ * If you need a car number, contact Bob Rankin at 503-472-2837 or mail 305 NW 2 nd . St., McMinnville, OR 97128 *Speedster Run Fees: Car, Driver, & Mechanic . . . . . . . . . . . . . $150.00 (includes Sat. Welcome BBQ, Sunday lunch, Awards banquet, 2 patches, & one dash plaque) Additional Saturday Evening Welcome BBQ . . . . . . . $15.00 Additional Sunday Lunch . . . . . . . . . . . . . . . . . . . . . . . $8.00 Additional Awards Banquet . . . . . . . . . . . . . . . . . . . . . $20.00 Patches _______ @ $6.00 ea. Dash Plaques ___________ @ $3.00 ea. Total Fees _______________ Amount Pre-paid _________________ Check #__________________ I have read the self-inspection details and all the rules governing this event and I hereby agree to abide by them. I understand that there will be a courtesy vehicle inspection prior to the start of the event and that this event is NOT to be construed as a speed contest. I hold the Northwest Vintage Speedster Club, its officers, and members harmless for any negligence, act, error, omission, injury, accident, or action that may arise from my or any other person’s participation in this event. I am covered by the minimum insurance requirements of my vehicle’s state of registration. Car Owner’s Signature ______________________________ Car Driver’s Signature ______________________________ (If different than car owner) Car Passenger’s Signature ___________________________ Date: ________________ Date: _________________ Date: _________________ Send Registration form and Speedster Run fees by May 1 st to: Ivan & Judy Dike 730 W. Ridgeway Ave. (Make checks payable to: “Desert to the Mountains Fun Run”) Hermiston, OR 97838 Cell Phones: 541-561-7123 or 541-561-7206 Email: dike97838@hotmail.com
“Desert to the Mountains” Fun Run WAIVER OF LIABILITY NORTHWEST VINTAGE SPEEDSTER CLUB Please read before signing & turn in with registration form (Each participant, whether driver or passenger, is required to sign this waiver) I understand and agree to all of the following as a condition to participating in a Northwest Vintage Speedster Club affiliated event: I have at least the minimum required vehicle liability insurance in the state of registration for any vehicle I am providing for participation in a Club affiliated event. I shall not hold the Northwest Vintage Speedster Club, it's officers or general membership liable for any negligence, act, error, omission, injury, accident or action that might arise during or from my participation or any other person's participation in any Northwest Vintage Speedster Club associated event. Northwest Vintage Speedster Club does not and shall not assume and shall not accept any responsibility for the safety or road worthiness of my or any other participant's vehicle, or for the safe driving and operation of any participant's vehicle. Any vehicle inspection performed at or by any Northwest Vintage Speedster Club event shall be as a courtesy only to assist the participant, and in no way shall imply any endorsement, assurance or guarantee of the safety or road worthiness of any participant vehicle Failure to provide a safe and roadworthy vehicle shall be the sole responsibility of the individual participant. No responsibility or liability whatsoever is implied by or shall be imputed to the Northwest Vintage Speedster Club, it's officers or general membership _____________________________ Print name of driver _____________________________ Signature of Driver _____________________________ Print name of participant _____________________________ Signature of participant ____________________________ Date
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