Registration & Bill Agency

First Name*

Last Name*

Age*

Phone Number*

Email*

Street Address*

City*

Zip Code*

Shirt Size* Shirt Size*SMLXL2XL3XL4XL

Division* Division*Harley WindshieldHarley FairingMetric

Category* Category*Police Motors OfficerCivilian

Type of Entry* Type of Entry*IndividualTeam

Class* Civilian riders are only eligible for novice and expert levels. Class* Civilian riders are only eligible for novice and expert levels.Novice - Any rider who has competed in fewer than 5 skills events & never received an individual event award.Expert - Any rider who has received an individual event award above 4th place.

Welcome event* - How many people INCLUDING YOURSELF will be attending the Wednesday night Welcome Event, pre-registration & dinner at WTAMU Agriculture Pavillion?

Track meal pass - Each rider will receive ONE Meal Pass for six meals & snacks at the track. Purchase additional passes for $20 per person. Indicate the ADDITIONAL Track Meal Passes you need

Banquet - tickets Each rider is provided ONE free banquet ticket and is allowed to purchase ONE additional ticket for $25. Indicate how many tickets you need, including yourself. Banquet - tickets Each rider is provided ONE free banquet ticket and is allowed to purchase ONE additional ticket for $25. Indicate how many tickets you need, including yourself. 1 Ticket - I will be attending the banquet without a guest 2 Tickets - I will be attending the banquet with only one guest

Marketing* - How did you hear about us? Marketing* - How did you hear about us?Past ParticipantFellow Officer or FriendFacebook / InstagramOnline CalendarLocal News CoverageOther

Emergency contact name*

Emergency contact number*

Is participant under the age of 18? Is participant under the age of 18? Yes

PLEASE READ CAREFULLY. BY SIGNING BELOW, YOU INDICATE YOU HAVE READ, UNDERSTAND AND AGREE TO THE FOLLOWING: I understand that participating in the above-referenced Activity may present significant risk of injury, including the potential for permanent paralysis and death or damage to my clothes or other property. While particular rules, equipment, and personal discipline may reduce this risk, the risk of serious injury does exist. I knowingly and freely assume all such risks, both known and unknown, even if arising from the negligence of the City and the 100 Club of the Texas Panhandle or others, and I assume full responsibility for my participation. Therefore, in consideration of being allowed to participate in the Activity, I agree to the following: 1. Photo Release. The City and the 100 Club of the Texas Panhandle may use my name, likeness, photo, picture, image, voice, and appearance in any video or audio recording, film, digital, or analog image, and the like (collectively, “photo”) taken by or made on behalf of the City and the 100 Club of the Texas Panhandle. The City and the 100 Club of the Texas Panhandle has complete ownership of such photo including the entire copyright, and may use such for any purpose of the City and the 100 Club of the Texas Panhandle. I will not receive any compensation for the use of the photo or the rights granted in this paragraph. 2. Release of Liability. I release the City and the 100 Club of the Texas Panhandle, its officers, employees, volunteers, agents, successors, and assigns from all liability, claims, causes of action, damages of every kind to myself or my property, judgments, attorneys’ fees, costs, and interest arising from or relating to my participation in the Activity and use of the facilities. 3. HOLD HARMLESS. I WILL DEFEND, INDEMNIFY, AND HOLD HARMLESS THE CITY AND THE 100 CLUB OF THE TEXAS PANHANDLE, ITS OFFICERS, EMPLOYEES, VOLUNTEERS, AGENTS, SUCCESSORS, AND ASSIGNS FROM AND AGAINST LIABILITY FOR ALL CLAIMS, SUITS, DEMANDS, DAMAGES OF EVERY KIND, COSTS, AND ATTORNEYS’ FEES THAT ARISE OUT OF OR RELATE TO MY ACT OR OMISSION OCCURRING DURING MY PARTICIPATION IN THE ACTIVITY.

Type out your name as signature*

Today's Date*