AHRMA National Trial Entry Form
Mosteller Ranch, Casper, WY
Rounds 14, 15 & 16 / Sep 3, 4 & 5, 2011

Name______________________________________________________ Member #____________
City_________________________________ State/Province___________ Zip____________
Phone_______________________ Email_____________________________________________
Insurance Co./Policy #_________________________________________________________
Age_____ Team Owner_____________________ Sponsors______________________________


Class Comp # Skill level Year/Brand/Chassis cc's Day 1 Day 2 Day 3

Membership if due:


Benevolent Fund donation:




MasterCard/Visa #______________________________________ Expires_____________

READ THIS RELEASE: I hereby release and agree to hold harmless AHRMA, the AMA, the promoters, the owners, and lessees of the premises, the participants, sponsors, and the officers, directors, officials, representatives, agents and employees of all of them of and from all liability, loss, claims and demands that may accrue from any loss, damage or injury (including death, loss of limbs and permanent disablement) to my person or property in any way resulting from or arising in connection with this event, and whether arising while engaged in competition or in practice or preparation therefor, or while upon, entering or departing from said premises, from any cause whatsoever. I know the risk and danger to myself and property while upon said premises or while participating or assisting in the event, so voluntarily and in reliance upon my own judgment and ability, and I thereby assume all risk for loss, damage or injury (including death, loss of limbs and permanent disablement) to myself and my property from any cause whatsoever. I have no known PHYSICAL PROBLEMS that will endanger myself or others while participating in this event.
HELMET STANDARDS: My helmet meets the standards set forth in the AHRMA Handbook for the category of competition I have entered.
AGREEMENT: By my signature below I agree to the terms of the above release, and further agree to abide by the AHRMA Handbook and any special regulations during the event.

Please check: No Yes No Yes
Contacts [] [] Dentures [] []
___________________________________ Asthmatic [] [] Diabetic [] []
Rider Signature Epileptic [] [] Hemophilliac [] []


SEND COMPLETED ENTRY FORM TO: AHRMA Entry, 309 Buffalo Run, Goodlettsville,  TN 37072, or fax to 615.420.6438. Payment must accompany form or entry will not be accepted. Entries for regional events are not to be sent to the national office.