Name ______________________________________ Phone No. ___________________________________ Social Security # ______________________________ Email____________________ Address ______________________________________________City ________________ State _______ Zip___________ Date of birth _______________________ Age as of January 1, 2006 _________ No. of Years Racing ________
Make & Year of Cycle __________________ Engine Size ____________ Cycle Serial # (optional) _____________________ I am covered by medical insurance _________Yes _________ No Tracks: ALL Are you currently an AMA member? _________Yes _________ No Last years bike # __________ Do you wish to keep this number for 2006? Yes or No Please circle one Your last years bike number will be held until March 15, 2006. Pick 4 numbers in case your first choice of bike number is taken. _______ ________ ________ ________ RELEASE & WAIVER OF LIABILITY AND INDEMNITY AGREEMENT All Sanctioned Western New York Motocross Association Inc. events IN CONSIDERATION of being permitted to enter for any purpose any RESTRICTED AREA (herein defined as including but not limited to the racing surface, pit areas, infield, burn out area, approach area, shut down area, and all walkways, concessions and other areas appurtenant to any area where any activity related to the event shall take place), or being permitted to compete, officiate, observe, work for, or for any purpose participate in any way in the event, EACH OF THE UNDERSIGNED, for himself, his personal representatives, heirs, and next of kin, acknowledges, agrees and represents that he has, or will immediately upon entering any of such restricted areas, and will continuously thereafter, inspect such restricted areas and all portions thereof which he enters and with which he comes in contact, and he does further warrant that his entry upon such restricted area and that he finds and accepts the same as being safe and reasonably suited for the purposes of his use, and he further agrees and warrants that if, at any time, he is in or about restricted areas and he feels anything to be unsafe, he will immediately advise the officials of such and will leave the restricted areas:
EACH OF THE UNDERSIGNED expressly acknowledges and agrees that the activities of the event are very dangerous and involve the risk of serious injury and/or death and/or property damage. EACH OF THE UNDERSIGNED further expressly agrees that the foregoing release, waiver, and indemnit agreement is intended to be as broad and inclusive as is permitted by the law of the Province of State in which the event is conducted 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 INDEMNITY AGREEMENT, and further agrees that no oral representations, statements or inducements apart from the foregoing written agreement have been made.
*** Every Rider must provide proof of age - Birth Certificate, School Records, Drivers License *** *** This must be filled out and officially notarized for anyone under the age of 18 years. *** I, _______________________________________ as parent or legal guardian further agree to hold harmless the promoter, participants, racing association, sanctioning organization or any subdivision thereof from any and all law suits commenced, by my infant in his/her own behalf or as his/her guardian. I also realize the possibility of serious injury or death to my infant due to the activity. Parent or Legal Guardian Signature: ____________________________________________________ Participant’s Signature: _____________________________________________________________ Subscribed and Sworn to before me this ___________________ day of ________________________ 20 ________ My commission expires: _________________________ Notary Public Seal:
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