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DAY PASS APPLICATION
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PEACE MOTOCROSS ASSOCIATION
Membership/Waiver of Liability & Indemnity Agreement
Revised 2010
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Rider’s Full Name:____________________________Birthdate (m/d/y)____________________
Address (Complete)_____________________________________________________________
Town: __________________________________________ Postal Code ___________________
Phone No. ____________________________ Email Address ____________________________
P.M.A. Race No. __________ Transponder # Assigned __________________
CLASSES REGISTERING IN:
NOTE: Numbers / Background Colors in ( )
50cc (4-6 years) (Red/White)
50cc (7-9 years) (Black/White)
60cc (Age 7-11)
80cc (Age 7-11) (Red/White)
80cc (Age 12-16) (Black/White)
Supermini (60-80cc)
Youth (Age 13-24)
Quad
Ladies A
Ladies B
125 Novice (Red/ White)
125 Junior (Red/ Yellow)
125 Intermediate (Black/Yellow)
125 Expert (Black/White) DAY PASS FEE (Please Mark):
or (White/Black)
250 Novice (Red/White)
250 Junior (Red/Yellow) 1st DAY PASS $25.00
250 Intermediate (Black/Yellow) 2nd DAY PASS $25.00
250 Expert (Black/White)
or (White/Black)
Vet Master
Vet Junior
Day Pass Fee Enclosed: $ ___________
BOTH SIDES OF FORM MUST BE FILLED OUT AND SIGNED AS APPROPRIATE
PEACE MOTOCROSS ASSOCIATION- DAY PASS
Membership/Waiver of Liability & Indemnity Agreement
Revised 2010
WAIVER OF LIABILITY & INDEMNITY AGREEMENT:
I have read the PMA Rules & Regulations and I, on behalf of myself and entrant(s) and the owner(s) of the vehicle mentioned herein, agree to be bound by them and by the PMA Rules & Regulations. In consideration of the acceptance of these events or of my being permitted to take part in these events. I, on behalf of myself, entrant(s), the owner(s), and their respective heirs, executors, administrators, successors, and assignees, agree at all time to release, defend, save harmless, and keep indemnified the Peace MOTOCROSS Association, the organizers, and their respective agents, officials, servants, representatives, and affiliates against all actions, claims, and suits, whether groundless or otherwise, and from liabilities, losses, damages, costs, charges, counsel fees, and any other expenses of any nature and character incurred by said bodies, their agents, officials, servants, representatives or affiliates, in respect of death, injury, loss of or damage to my person or property, or to any and all persons and property howsoever caused arising out of or in connection to or occasioned by the negligence of the said bodies, their agents, officials, servants, representatives of affiliates.
YES “ I AGREE TO ALLOW MY CHILD, CHILDREN, OR MY NAME, RACE NUMBER, CLUB & TOWN, TO APPEAR ON THE PMA WEBSITE, RADIO, OR NEWSPAPER.”
NO “I DO NOT AGREE TO ALLOW MY CHILD, CHILDREN, OR MY NAME, RACE NUMBER, CLUB, TOWN, TO APPEAR ON THE PMA WEBSITE, RADIO, OR NEWSPAPER.”
The undersigned has read and voluntarily signed the release and waiver of liability and indemnity agreement, and further agrees that no oral representations, statements, or inducements apart from the foregoing written have been made. I have read this release.
_________________________ ______________ ____________________________
(Signature of Rider) (Date) (Make of Motorcycle)
If signatory is under 18 years of age, parent or guardian’s signature is required and the parent/ guardian both on behalf of the child personally adopt in full covenant of indemnity & waiver of liability detailed above.
________________________________ ___________________________________
(Signature of Parent/Guardian) (Printed Name of Parent/Guardian)
I WOULD LIKE A RECEIPT ISSUED: YES or NO
MAKE APPROPRIATE PAYMENT TO:
Peace Motocross Association
Attn: Tammi Doll
RR1 S15 C62
Fort St. John, BC, V1J 4M6 (250) 787-5514
BOTH SIDES OF FORM MUST BE FILLED OUT AND SIGNED AS APPROPRIATE
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