Name (required)

Address (required)

City / State / Zip (required)

Cell Phone

Home Phone

Email Addr (used ONLY for this event)

How did you hear about us?
WebsiteOther Event WebsiteFacebookAttended Prior Yr

CAR / TRUCK / BIKE INFORMATION: (Anything on wheels accepted!)
Make

Model

Year

Modifications - Details

WAIVER:
I, the undersigned, do hereby waive and release Stability First, Inc, its officers volunteers and event
workers from any and all rights and claims for damages, which may relate to my involvement in today’s event. I
agree to assume all responsibility for, and to indemnify, defend and save harmless Stability First Inc. from and
against, any and all liability, judgment, attorney fee and cost, claims, demands, or loss from damage, destruction,
injury or death, which may occur or result from my, or my minor child/ward’s involvement in this event. I make this
WAIVER, RELEASE AND INDEMNIFICATION on behalf of myself and my personal representative, heirs, minor
child/ward, assigns and estate. I HAVE READ THE ABOVE STATEMENTS. No other representations (oral or otherwise)
have been made apart from this document altering its meaning. Unless otherwise indicated, I certify that I am at
least eighteen years of age. I am signing this WAIVER, RELEASE AND INDEMNIFICATION of behalf of myself and any
minor (s) accompanying me.

Name (required)

Address (required)

City / State / Zip (required)

Email Addr (used ONLY for this event):

Rider Name: