Red Ballin’ Thru the Ozarks - Registration

Hosted by Arkansas MV Travelers

2 APR 2008       Red Ball Convoy

Please print these pages (this will print as a white page with black print)

*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 form to be received no later than 1 April 2008  DEADLINE extended to 20 Apr 2008 *Registration fee of $15.00 per participant must accompany your form.   (Under 5 free, 6 - 16 $7.50) (please make checks payable to AR MVPA)  *If an email address is provided we will acknowledge receipt of your registration via email.  *Registration can not be accepted via email. We must have original hard copies.  *Make copies of this form for your records and have a copy with you.

Vehicle Participant Information

Name:_________________________________________________

Organization affiliation (if any):____________________________

Address:_______________________________________________

_____________________________________________________    

Phone:________________________Email:____________________

Fax (if available):_______________________________________

Vehicle Registration

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: _____   Make: ______        Model: ________                          

             Plate#:  _________   State: ________   Exp.  Date: _________      

         Please list names of any persons that will be riding with you.

Rider #1_____________________  Rider #2_____________________

Rider #3_____________________  Rider #4_____________________    

Rider #5_____________________  Rider #6_____________________

 

 

 

Liability Release and Indemnity Agreement

I, _______________________ wish to be a participant 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 traveling 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 does exist 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 this risk does exist.

In consideration 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 the 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 this Liability Release Waiver 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 appropriated 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 Number: ____________________

Name: __________________________ Phone Number: ____________________

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: ____________

Complete this form and mail to: 

Marsha Jones, Convoy Registrar    11091 Royal Oaks    Prairie Grove, AR 72753

Make Checks payable to Arkansas MV Travelers. Event fee is $15.00 per person. The fee includes lunch.  No refunds after April 1, unless the event is cancelled.