Registration
2010 Red Ballin’ thru the Ozarks Convoy: 1 May 2010 Hosted by the Arkansas MV Travelers
*Please complete all sections of the form. If a section doesn’t apply to you, please enter “N/A”. All vehicles must be licensed and insured. All participants must sign the liability waiver. Please mail this registration to be received no later than 14 April 2010. Registration fees to accompany your form (17 & up-$15.00; 6-16 yrs-$7.50; 5 and under- no charge). Please make checks payable to AR MVPA.
Vehicle Participant Information:
Driver Name:________________________________________
Affiliation (if any): ___________________________________
Address: ___________________________________
___________________________________
Phone: ___________________________ Email: ___________________________________
Vehicle Registration:
If you’re registering multiple vehicles- list additional vehicles on the back of this page. If you are riding only, please “X” out this section and write “Rider Only”.
Vehicle:
______________________|_____________________________|_________________________________
Year Model/Type Manufacturer
______________________|_____________________________|_________________________________
Plate# State Exp. Date
Please list names of any persons that will be riding with you:
Rider #1: ________________________________
Rider #2: ________________________________
Rider #3: ________________________________
Rider #4: ________________________________
Mail to: Marsha Jones-Casey/Convoy Registrar; 11091 Royal Oaks; Prairie Grove, AR 72753
Make checks payable to AR MVPA. Event Fees include lunch. No refunds after 14 April 2010 unless the event is cancelled. An after-convoy dinner will be served Saturday evening. If you plan to attend the dinner please include the additional fees (see Dinner Section).
Red Ballin’ Fees
Convoy Fees:
No. of Convoy Participants (17 and over): _____________X $15.00 = ______________
No. of Convoy Participants (6-16 years): _____________X $7.50 = ______________
No. of Convoy Participants (5 and under): No Charge
Convoy Sub Total: $______________
After-Convoy Dinner Fees:
Will you be participating in the after-convoy dinner? Circle one: YES NO
If “Yes” – please fill out the section below:
No. of Dinners (17 and over): ___________X $10.00 = _____________
No. of Dinners (6-16 years): ___________X $8.00 = _____________
No. of Diners (5 and under): No Charge
Dinner Sub Total: $____________
(from above) Convoy Sub Total: $____________
Grand Total: $____________
Important Information – Must Read!
Please mail your registration to be received no later than 14 April 2010. Registrations mailed later than this may be returned. This is to allow for adequate planning and determination of convoy line-up.
Make checks payable to AR MVPA
Mail to: Marsha Jones-Casey/Convoy Registrar 11091 Royal Oaks Prairie Grove, AR 72753
Liability Release and Indemnity Agreement
I, _________________________ wish to participate in the Red Ballin’ thru the Ozarks Convoy hosted by the Arkansas MV Travelers.
I acknowledge that by participating in the Red Ballin’ thru the Ozarks Convoy I will be travelling on roads that may contain typical roadway hazards such as debris, gravel, various obstructions as well as other motorists not involved in the convoy. I further acknowledge and agree that there exists a significant risk of injury that could include the potential for serious injury, permanent paralysis and death. I acknowledge that guidelines, rules, equipment and personal discipline may reduce this risk but that risk does exist.
In consideration for allowing my participation in this event, I hereby release and hold harmless the Arkansas MV Travelers, together with its volunteers, agents, officers, and members from any and all liability, claims and causes of action arising out of or in any way connected with my participation in this event or events hosted by the Arkansas MV Travelers with respect to any and all injury, disability, death or loss or damage to person or property, whether arising from negligence of the releases or otherwise to the fullest extent of the law. This Liability Release Waiver and Indemnity Agreement shall bind my heirs, personal representatives, assigns and all members of my family including any minors.
The Arkansas MV Travelers, together with its volunteers, agents, officers and members, does not own or operate any entity which is to, or does provide goods or services for your trip including, for example, lodging facilities, transportation companies, food service providers, equipment suppliers, etc. As a result, the Arkansas MV Travelers is not liable for any negligent or willful act or failure to act of any such person, or of any third party.
I understand that the Arkansas MV Travelers reserves the right to refuse any participant, or remove from the convoy/event, any person it judges to be incapable of meeting the requirements of the event, or who it determines to detract from the enjoyment of the trip by others. I agree to follow all written and verbal rules of safety presented to me by the Arkansas MV Travelers.
I understand that this Liability Release Waiver and Indemnity Agreement is a contract and not a mere recital and that it shall remain in effect for all events sponsored by the Arkansas MV Travelers. I have read and understand the Liability Release and Indemnity Agreement in its entirety. *I am over the age of 18 years.
Signature:______________________________ Date:________________________
Medical Permission with Information and Health Statement
In case of emergency, accident, or illness, I give my permission to be treated by persons qualified through first aid or other appropriate medical training, transported by any means available, and admitted to a hospital if necessary.
I acknowledge that I am in good health and have the physical capacity to participate in this convoy/event or any other event sponsored by the Arkansas MV Travelers.
Signature:______________________________ Date:___________________________
Person(s) to notify in case of emergency. List TWO persons if one person is participating in this same event.
Name: ________________________________ Phone No.________________________
Name: ________________________________ Phone No. ________________________
Please list any other medical information for which we should be aware of in case of emergency.
Photography Permission
I agree to give my permission to allow photographs to be taken during the convoy/event in which I participate to be used by the Arkansas MV Travelers. I understand that this includes appearing in, but not limited to, the mass media such as newspapers, magazines, websites, or presented to the public, individuals and others in public relations documents, books, posters and any other media.
Signed:_________________________________ Date:____________________________
Make all checks payable to: AR MVPA
Mail all forms to: Marsha Jones-Casey/Convoy Registrar
11091 Royal Oaks
Prairie Grove, AR 72753