MOTORCYCLE RIDE REGISTRATION FORM --- by ikn20172

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									           The Stan Wilkins Annual Motorcycle Ride & Car Show
                                Hosted by Cartersville First Baptist Church


 --- MOTORCYCLE RIDE REGISTRATION FORM ---
                       Saturday May 15, 2010 - Registration 9 a.m.
               Leaving from Cartersville Harley Davidson on Hwy. 411 at 10 AM
Participant:
Last name ______________________ First name
Mailing address
City ________________________________ State _______ Zip
Home phone______________________ Cell
Emergency contact
Relationship_______________________ Phone
Medical problems
Passenger:
Last name _______________________ First name
Emergency contact
Relationship______________________ Phone
Medical problems
Vehicle:
Year_____ Make_______________ Model____________ Color
Tag #________________ State____ Insurance Co.

WAIVER:
By signing below I hereby acknowledge and accept the inherent risks involved in motorcycle
riding activities and car & bike show activities and agree to indemnify and hold Cartersville
First Baptist Church, its employees, agents, volunteers and assigns harmless against any and all
claims of injury, loss or other claim of whatever nature that may in any way arise out of my
participation in the charity ride or its attendant activities held of even date herewith.

________________________________                        _________________________________
PARTICIPANT SIGNATURE                                   PASSENGER SIGNATURE
                           T-shirt while supplies last - REGISTER EARLY TO GUARANTEE
                         Bike Rider - lunch & t-shirt (size______)   $25                       =   $
                          Passenger - lunch & t-shirt (size______)   $10                       =   $
                                         Extra HDTV tickets $5 x ______                        =   $
                                              Extra lunches $5 x ______                        =   $
                         Extra t-shirts Sizes___________     $10 x ______                      =   $
                                  Additional tax deductible contribution                           $
  Circle: Cash / Check                                                                     Total $
  (Payable to Cartersville First Baptist Church - notate Stan Wilkins Ride and Car Show)
                 Net proceeds go to Stan and Gail Wilkins Scholarship Fund
      North Georgia Campus of New Orleans Baptist Theological Seminary - Marietta, GA
             Information at www.cartersvillefirst.com 770-382-4994
                              241 Douthit Ferry Road - Cartersville, GA 30120

								
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