QIVEQSmE INTL.IlJICEWDYI ~lri
APRILPRIX
.1U6, 197.1
BBERTHERR BIIJIJIll
NOV ICE
Orllnlle, ellu f.
9Z667
Phone (714 ) 636-0CMC
or
(714) 636-6262
0 - 100
J U NI O R
MOTO-X
10 1 - 125
EX PE R T
SCRAMB LE
12 6 - 17 5
UNCLASS
PWDR ·PU FF
17 6 - 2 50
HACKS
P.o. Do" 60Z6
DESERT
251 - 500
SE NIOR
OPEN
D ist . Riding No .
RIDERS PLEASE CHECK CORRECT BOX
Mail En t ry $ 12 .00 a r id er - Po st Entry $ 100.00
ENTRY MUST BE ACCOMPANIED BY 2 SELF·ADDRESSED, STAMPED, LEGAL SIZE ENVELOPES
PLE ASE PRI NT CLEARLY
D ist No .
Na m e
City
Add ress
State
Club
En g. Si ze
Zip
_
--'Ph o n e
Make B i k e
Age _
.
AMA #
_
Expr ies
_
T HE UNDERS IGNED ENT RA NT BY A F FI X I NG HI S INITI ALS BELOW, ACKNOW LEDGES T HAT HE ASSUMES T HE RISK OF AN Y LOSS
FROM I NJU RY OR PROPERT Y DAMAGE TO H IMSELF OR TO OTHERS, DUE TO H IS PARTICIPATION IN TH IS EVENT AND HE
HEREWI TH SPECI FI CAL LY HO LDS HAR MLESS FROM ANY SAID LOSS THE AMERICAN MOTORCYCLE ASSOCIATION , SPORTS
COMM ITTE E , DISTRICT 37 AMA, INC.• THE SPONSOR ING CLUB OR ORGAN IZATION , A ND THE OWNE RS OF THE REAL PROPERTY
ON WHI CH SA ID EV ENT SH A L L T AKE PLAC E.
(ent rant's an d /or par en t 's ini ti als )
T he undersi qned does her eby cer t if y th at he is a dul y qualified (C tr cte O ne) Ju nior/E xpert/Nov ic e cla ss motorcycle r ide r hav ing been so qual ified by a
co mpe tent organ izat ion .
It is furt her u nde rst ood a nd agr eed that in t he event I am inj ured from whatsoever cause during the event covered by th is appl ication . I herewith co nsent
t o and authorize f ir st aid and ambul an ce servi ce as provid ed b y t h e sp o nsori ng c lub or property owner, and f urther hold all part ies harmless f rom any
co nsequ enc es o f said aid .
Under the ru les and sanct ion s o f the Amer ican ~o torcy cl e As sociat io n, I he reb y agree to conform and com p ly with the rul es gov ern ing th is contest.
Signature of entr ant
Date
19
If en t rant is u nd er 18 and does no t have a cu r ren t D istric t 37 Card ind icat ing notariz ed consent is o n f ile, Parent or G uardian mu st sign h ere acknowl ·
edg ing h is or her notarized con sent to th e terms of entry.
I
NOTICE - THE BELOW INFORMATION TO BE USED BY RESCUE FORCES ONLY.
M aleI F emale
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=-E=R:::
'SC":N-:-A:-M=E-
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AGE
STREET ADDRESS
G.P.
No .
. - - - --
CITY
PERSON TO NOTIFY IN CASE OF ACCIDENT
STATE
-
PHONE
PHONE
RELATIONSHIP
YOU R BLOOD T YPE
YOUR INSURANCE COMPANY
POLICY NUMBER
19
