Please
type or print clearly. If you wish to
receive a t-shirt on Sunday, May 3, 2008, please mail (postmarked by Monday, April
20, 2009) the following 2009 Boot State Power Run registration form to Pinnacle
Performance, P.O. Box 143, Charenton, LA 70523.
You can also register at 9 a.m. on Sunday, May 3, 2009.
|
Name (Primary Rider) |
|
|
Address |
|
|
|
|
|
|
|
|
Phone |
|
|
Email |
|
|
Age |
|
|
T-Shirt Size |
|
|
Riding
Experience |
years |
|
Emergency
Contact |
|
If applicable
for a passenger:
|
Name (Secondary
Rider) |
|
|
Phone |
|
|
Email |
|
|
Age |
|
|
T-Shirt Size |
|
|
Riding
Experience |
years |
|
Emergency
Contact |
|
Please
check one.
o
To
receive a shirt on Sunday, May 3, 2009, and speed the registration process, I
have enclosed a nonrefundable registration fee in the amount of $25 per bike,
made payable to Pinnacle Performance, and remitted to P.O. Box 143, Charenton,
LA 70523.
o
To
receive a t-shirt on Sunday, May 3, 2009, and speed the registration process, a
nonrefundable registration fee in the amount of $25 per bike has been made via the
PayPal link at http://www.pinnacleperformance.biz.2009bootstatepowerrun.html.
o
I
have elected to register on Sunday, May 3, 2000, at 9 a.m.
In
consideration of the acceptance of this entry thereby for myself, my heirs,
executors, and administrators waive and release any and all claims and damages
I may have against labodybuilding.com, Pinnacle Performance Physique and Strength
Sport Enterprises, Inc., members and staff, their representatives, successors,
and assigns for any and all injuries or bodily harm that I may suffer while
riding in the 2009 Boot State Power Run.
I attest and verify (as the primary rider) that I can legally operate a
motorcycle with a current endorsement and insurance, and (as primary rider and
secondary rider) have full knowledge of the risks involved with my
participation of this event.
Primary Rider Signature
_________________________ Date
_______________
Secondary Rider
Signature _________________________
Date _______________