Highway to Help - Adopt a Family
3 Hour Ride COVERED BRIDGE RIDE t Firs nder po s RE DISplay HIGHWAY TO HELP! Adopt-A-Family Atrium MEdical Center 1 Medical Center Drive August 1, 2015 Rain or Shine! Ohio State Patrol Motorcy Cle DiSPLAY E L F F RA T-SHIRT SALES $25.00 Registration Fee EVENTS STARTS •10:00 a.m. Registration • 10:00 a.m. – 11:30 a.m. Covered Bridge Ride Kickstands Up Leave 12:00 p.m. Sharp Cookout and Prizes after ride at The Brewery Inn, Trenton, Oiho to Benefit Adopt A Family At Atrium Medical Center Highway to Help Saturday, August 1, 2015 Name: Mailing Address: City/State/Zip Email Address: Cell Number: Emergency Contact Name: Emergency Contact Number: T‐Shirt: ____ S ____ M ____ L ____ XL ____ XXL _____ $25 (Adult with one meal) No additional charge for passengers. _____ $10 T‐Shirt _____ Extra Meal(s) $5 each $____ Donation, I am unable to participate. Total Enclosed: $____________ Please make checks payable to: Atrium Medical Center Foundation Credit Card Number:_________________________________ Exp. Date: ____/____ Security #: ________ Name on Credit Card: _________________________________________ ___ MasterCard ___ VISA ___ American Express ___ Discover All personal information will be held strictly confidential and private. By participating in this event, I acknowledge, understand and agree to the following terms and conditions: I agree to accept all responsibility and financial liability for any damages, claims, or assessments resulting directly or indirectly from my actions while participating in this event, and I agree to indemnify, not to sue, and to release and hold harmless from any liability Atrium Medical Center, its affiliates, and its directors and officers; Atrium Medical Center Foundation, its directors and officers; its sponsors, its volunteers; other motorcyclists, and any of its past, present, or future beneficiary organizations (collectively, "Releases"). In considerationof the benefits of participating in this event, I hereby freely agree to make the contractual representations and agreements herein. Motorcycling is a dangerous sport and includes the risk of personal and bodily injury. I fully realize the dangers of participating in this event, and I fully assume the risk associated with such participation including, without limitations, dangers arising from surface hazards, equipment failure, inadequate equipment, use of others' equipment, the Releasees' own negligence, the negligence of others, weather conditions, and the possibility of serious physical or mental trauma or injury. Motorcyclists share roadways with automobiles, trucks and other vehicles under normal, hazardous traffic conditions. Releasees do not guarantee roadway or traffic safety. I agree to practice safe motorcycling at all times while participating in this event. I will provide necessary equipment, wear appropriate clothing, eyewear and DOT‐approved motorcycle helmet. I agree to follow all applicable traffic laws and to ride in safe Parade formation in a group riding two abreast. Should I assert a claim contrary to this contract, the claiming party shall pay all costs that Releasees incur in their defense. I am physically fit to participate in the event at the level I have registered and no limitations – physical, mental or otherwise – prevent my participation at that level. If my image appears in any graphics, photos or video, I grant permission to use such images for publicity purposes. I agree, for myself and my successors, that this release is a legal and binding contract. I have read it carefully before signing, and I understand what it means and to what I am agreeing by signing. Participant Passenger Signature ___________________________________________ Signature___________________________________________ Send completed form and payment to: Atrium Medical Center Foundation, One Medical Center Drive, Middletown, Ohio 45005; fax to 513.705.4165; or email to [email protected] This is a rain or shine event.
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