Name______________________________________________________ Member #____________
City_________________________________ State/Province___________ Zip____________
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.
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.