THE BEAR IS B:A:CK···· ...
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ARen 23 ~ 24 ••
R/V£RSIDG INTERNATIONAL RACEWAY
GREAT BEAR G.P.
P.O. Box 6026
Orange, Ca. 92667
NOVICE
DESERT
0
AMATEUR
MOTO -X
101 - 175
EXPERT
SCRAMBLE
176-250
UNClASS
PWDR·PUFF
251 - 500
HACKS
501 - 650
OLD TIMER
OPEN
Phone (7 14) 636-0CMC
or (7 14) 636-6262
DIST . No .
- 100
RI DERS PLE A SE CHE CK CORRECT BOX
Mail Entry $10 .00 a rider - Post Entr y $1 00.00
ENTRY MUST BE ACCOMPAN IED BY 2 SELF ADDRESSED, STA MPED, LEGAL SIZE ENVELOPES
PLEASE PRINT CL EA R L Y
_ _ _ __ _ Name
_
Address
_ _ _ _ _ _ _ _ Club
_
Phone
_ __ _ _ __
AMA#
Expires
_
_
Age
_
T HE U N DE R SI G N E D E N TRA N T B Y A FFIX ING H IS INITI A LS BELOW . ACKNOW LEDGES THAT HE ASS U MES THE R ISK OF
AN Y L O SS FROM INJU RY OR PROPERTY DAMAGE T O H IMS E L F OR T O O T H ERS . D U E TO HIS PA RTICI PATION I N THI S
EVENT AN D H E HER E W ITH SPECI F ICAL L Y HOLDS HARMLESS FROM AN Y SAID L O SS THE AMERICAN MOTOR CY CLE
A SSO CIA T IO N . SPO RTS C OM MITTEE . D ISTR IC T 3 7 AMA , INC .. TH E S PONSORI NG CLUB OR ORG A N IZ A T ION , AND T HE
O WNERS O F T H E REA L P R O P E RTY ON WH ICH SAID EVEN T SH A L L T AKE P LAC E .
(entrant's e nd /or pa rent's in it lels)
h e unders igned does hereby c e rtify that he is a duly Qu a lified (Cir c le One ) Amat eu r /Expe rt/ Nov ic e class motorcycle ri d e r ha v in g been
o qualified by a competent organ iz etion .
"
t is further understood and a areed tha t in the event I em injure d from whatsoever c ause d uring t he e vent covered by th is e p pl ic a tion,
her~ith con sent to and authorize f irst a id and ambulance service a s prov ided b y t he spc nso rina cl u b or prope rty own er . and f urther
old a ll p arties harmless from any ccoeeeuencee of sa id a id .
nder t h e rules end sa nctio ns of the Ame r icen Motorcyc le Assoc iatio n . I h ereby egre e t o c onfo rm and comply w ith the rules Kover n ina
h is c ont es t.
_ __
_ __
_
_ _ __ _ _ __
19_ _
If entrant is under 18 and does not have a current District 37 Ca rd i ndicat ing not ar i zed
consent is on f i le, Parent or Guardian must sign here acknowledging hi s or her notarized
consent to the terms of entry.
MALE /FEMALE
RIDER S NAME
ST REET ADDRESS
PERSON TO NOTIF Y IN CASE OF ACCIDENT
REL A T IONSHI P
YOUR INSUR ANCE COMPAN Y
AGE
CITY
G.P. No.
STAT E
PHONE
PHONE
YOUR BLOOD TYPE
POL I CY NU M BE R
3
