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Rider's Name:

Age:

Gender:

Passenger Name:

Age:

Gender:

Address:

City:

State:

Zip:

Motorcycle Make:

Model:

Year:

Direct Miles from Rally:

sidecar?

email address*:

*So we can let you know you are registered
Club affiliation:

READ THIS BEFORE SIGNING: This is A Release And Waiver Of Liability And Indemnity Agreement.
In consideration of my being permitted to participate in the Northern Riders BMW Club of Alaska 2007 last Frontier Rally (the Rally). I hereby waive all rights to sue or make any claim for injury or damages due to negligence or any other reason whatsoever against the Northern Riders BMW Club of Alaska, the Matanuska-Susitna Borough, the City of Houston and its members, officers, and employees and all other persons, participants or organizations conducting or connected with a Rally event or activity for injury to person or damage to property that I may suffer, including crippling injury or death while participating in any event or activity or the Rally and while upon Rally premises. I know the risks of danger to myself, my minor child (if present) and my property while participating in the Rally events and hereby agree to pay and reimburse to those persons or organizations connected with this event the costs, losses and damages incurred or suffered as a result of my negligence. I do for myself, my heirs, executors, administrators, successors, and assignees, hereby release and waive all rights and claims for damages, losses or injuries incurred by me at the Rally.

Rider Signature:_______________________________________

Date:

Passenger Signature:____________________________________

Date:

Number of Riders:

X $30.00 U.S. (or $35.00 after 6/01/07)

= $

Number of Passengers:

X $20.00 U.S.(or $25.00 after 6/01/07)

= $

Number of children 6-12:

X $15.00 U.S.

= $

Subtotal

= $

Rally T-shirt
(how many each size)

S

M

L

XL

XXL

Times $18.00

Subtotal

= $

GRAND TOTAL

= $