Make checks payable to : Aliceville Rotary Club Mail to : Aliceville Rotary Club c/o James Owens 323 County Road 13 Aliceville, AL 35442 Name:__________________________________________ Age:____________ Sex: M / F Address:_________________________________________ Birth Date:________________ City:___________________________ State:______ Zip: ________ Phone: ____________ I, individually, (and/or as parent, and/or guardian of the named minor) for and in consideration of acceptance of this entry in the aforementioned event, do hereby release, remise,waive, and forever discharge the Sponsor and any and all other supporting groups of this said racing event, together with all of their officers, agents, officials, and employees from any claims, demands, actions, or cause action whatsoever arising out of, or relating to any injury, illness, loss, or damage, including death, relating to participation in the aforesaid event. I further state I am in proper physical condition to participate in this event. Signature: _____________________________________________ Date:______________________ |