Print this Page, Complete and Bring with you to the Ride. Also if you

Prepay, bring a copy of your Pay Pal receipt. You can pre - pay by using

the Buy It Now button at the bottom of the page. Use the Pull down menu

to select Single or Double.  Then enter the amount and quanity.

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Douglas Rays Ride for Kids

Poker Run Registration Form

Name __________________________________________________________________

Address ________________________________________________________________

City ________________________________ State ________ Zip ______________

Phone (_________) ______________________________________________________

E-mail _________________________________

REGISTRATION FEE

$15.00 Single / $20.00 Double

You must be registered before August 16th @ 11:00 PM .

For more information call (704) 223-2944

Douglas Ray's Ride For Kids

RELEASE AND ASSUMPTION OF RISK

(All participants must sign)

In signing this release, I acknowledge that I understand its intent, and for myself, my heirs,executors, administrators,

and representatives do hereby agree and will absolve and holdharmless The CUD Foundation, Douglas Rays Ride

and any other sponsors of this event, cooperating organizations and other parties connected with the event in any way,

together with their respective successors and assignees (the sponsors), singly and collectively from and against blame

and liability for any injury, harm, loss, inconvenience, or any damage of any kind, which may result from, or be connected

in any way to my participation in the Douglas Ray's Ride For Kids.

In addition to release from all liability, I hereby represent that I agree to observe all traffic and event rules and will

conduct myself in a safe and prudent manner while participating in the event. I hereby absolve and hold harmless the

sponsors from any damage I may sustain because of breach of these representations. I hereby consent to and permit

emergency treatment in the event of injury or illness while participating in the event. I also give permission to the

CUD Foundation, Douglas Ray’s Ride, Rally at the River and Parents of Douglas Alley  to use my

name and any photographs taken of me during the event in any promotional material or publications.

I certify that I have read this waiver and understand its significance.

Signature:____________________________Date________________________

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