Registration

Name:__________________________________________________________

Address:________________________________________________________

Phone#:_____________________

Email: ______________________________________ 

• $20.00 donation per person x _________ = $_______________

RELEASE AND INDEMNITY AGREEMENT – Please READ & SIGN.

I hereby give up all rights to sue or make any claim whatsoever against the event titled “Larry Lund Jr. Poker Run”, sponsors and all other persons, participants or organizations conducting or connected with the event for any injury to property or person I may suffer, including crippling injury or death, whether such injury arises, while I am preparing for or participating in the event or while I am upon the event premises. I know the risks to myself and my property, while participating in the event and while upon the event premises and relying upon my own judgment and ability to assume all such risks of loss and hereby agree to reimburse all costs to those persons or organizations connected with this event for damages incurred as a result of negligence. In addition, I will not consume alcoholic beverages beyond the amount accepted by law or use/sell drugs that could impair judgment during the event. I also understand that the event may be video taped and my image may be captured as well as sound bites, pictures of my likeness may be used for promotional purposes of this event and future events. I give permission to use such material and hold harmless the promoter or expect any form of financial compensation for the use of my image/likeness or sound bite.

Print Name: _______________________________________
Sign Name: _______________________________________
Date: ______________________