Name:____________________________ Age:______

Address:_____________________________________

City:___________________ State:____ Zip:________

Telephone:________________ Mobile:________________

Motorcycle Brand:____________________ Model:________________

$25 Per Person; $10 for an extra hand:_______ Amount:_______ paid

Cash________ Check#________ Money Order__________

Make Checks Payable to : Bell Buckle Chamber of Commerce

Mail Checks and Pre-Registration Forms To:
(Or Bring completed form to event for faster registration)
Chamber of Commerce
P.O. Box 222
Bell Buckle, TN 37020
931- 389-9663

For More Information Contact:
www.bellbucklemotorcycledays.com

Release and Indemnity Agreement- Read It Before Signing

In consideration for the right to participate in The Bell Buckle Poker Run ( The Event), the receipt and sufficiency thereof herby acknowledged, I give up all rights to sue or make claim for damages due to negligence or any other reason whatsoever against the Bell Buckle Chamber of Commerce, the Town of Bell Buckle, or any persons associated with conducting or participating in The Event. I will make no claim for injury to property or person I may suffer, including without limitation, crippling injury or death, while participating in the Event and while on the premises.

I know the risks of danger to myself and my property while preparing for and participating in the Event and while upon the event premises and, relying upon my own judgment and ability, assume all risks of loss and hereby agree to reimburse all costs to those persons or organizations connected with this event for damages incurred as a result of my negligence. I also agree to indemnify, defend and hold harmless the Bell Buckle Chamber of Commerce, The Town of Bell Buckle, or any persons associated with the Event from all claims, suits or causes of action arising out of or relating to the Event or my participation therein. This is a general release which I have read and understand.

Signature(s) of Participant(s)_______________________________ Date_________

Signature of Parent (for minor)______________________________ Date_________