P.O. BOX 1498
La Plata, Maryland 20646
REGISTRATION PLEASE PRINT OR TYPE
_____________________________________________________
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Last Name | First | Chapter
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________________________________________________ | _____________________________________________________
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Address |
| City | State/Prov | Zip Code
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______________________________________________ | _______________________________________________________
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Area Code | Phone No. | Email Address
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FULL WEEKEND (includes shirt) ($5.00 extra for L/S) | Number of Adults | _____x $55.00 S/S | ____x $60.00 L/S | $_____
#Children 8-15
_____x $30.00 S/S
____x $35.00 L/S
$_____
_____Free
$_____
FULL WEEKEND (without shirt)
Number of Adults
_____x $40.00
$_____
#Children 8-15
_____x $20.00
$_____
Children Under 8
_____Free
$_____
SATURDAY (PICNIC ONLY)
Number of Adults
_____x $20.00
$_____
#Children 8-15
_____x $15.00
$_____
Children Under 8
______Free
$_____
After May 5th, add $10 per person to your registration
**Total Enclosed
$__________
|
Please check size & color shirt
Shirt Size: S___ M___ L___ XL___ 2XL___ 3XL___ Shirt Type: ___Short Sleeve ____ Long Sleeve (limited sizes)
Shirt Color: Black___ Gray ___ OD Green ___
Will you be attending the Sunday Dinner?(head count only) yes___ no___
The participants, agree to indemnify and hold harmless, to waive any possible claim or right of action and to fully & forever release from any and all liability, the Blue Knights Law Enforcement Motorcycle Club, Inc., Maryland Chapter IV, its, members, officers, agents and/or directors from all claim, demands, suits, actions, or casuses of action whatsoever exisitng or which could possibly arise at any time in the future, as a direct or indirect result of my participation in Maryland IV Rolling Thunder Weekend, on May 23, 24,& 25, arising out of or in consequence any sickness, death, loss, personal injury, damage to my person or property, or expense whether predicted or not and I hereby, for me, my heirs, executors, administrators, successors and assigns agree to hold harmless, the Blue Knights Law Enforcement Motorcycle Club, Inc., Maryland Chapter IV, its, members, officers, agents and/or directors from all claim, demands, suits, actions, or casuses of action whatsoever exisitng or which could possibly arise at any time in the future, as a direct or indirect result of my participation in Maryland IV Rolling Thunder Weekend, on May 23 24 & 25 2007,arising out of or in consequence of any sickness, death, loss, personal injury, damage to my person or property, or expense incurred, notwithstanding that same may have arisen by negligence or the execution or attempted execution of a duty by a member of the Blue Knight Law Enforcement Motorcycle Club Inc., Maryland Chapter IV, or any other person for whom the grantees, are liable.
THIS IS AN ABSOLUTE WAIVER & RELEASE
I am aware that by signing, I acknowledge that I have read, understood and agreed to all of the above.
________________________________ _________________________________ _________________
Print Name: Signature: Date:
________________________________ _________________________________ _________________
Print Name: Signature: Date: