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Potomac HonorBound & Men’s MinistryStart: Life Church, Colonial Hgts, VA – to Carini’s

June 17, 2017

Registration, Release, and Ride Participation Form

RIDER (PLEASE TYPE OR PRINT) NOTE: Riders must be over 18 to participate in the ride
NAME:
Address:
City: ______State: ____ Zip: ______Phone:
Passenger (PLEASE TYPE OR PRINT) NOTE: Passengers under 18 must ride with legal guardian
NAME:
Address:
City: ______State: ____ Zip: ______Phone:
Guardians Waiver for Minor Participants must be completed below for a minor to ride as a passenger
REGISTRATION FEES
Rider: = $15
Passenger: = $10
TOTAL: $ / EMERGENCY CONTACT INFORMATION (PLEASE PRINT)
NAME:
Relationship: ______Phone:
NAME:
Relationship: ______Phone:
THIS IS A RELEASE – READ BEFORE SIGNING
By my signature below, I affirm my understanding and agreement to the Release, Consent, and Attest noted below.
Rider’s Signature:
NAME:
Date: / Passenger’s Signature:
NAME:
Date:
Guardians Waiver for Minor Participants: “Guardians Waiver for Minor Participants” must be signed for passenger’s below the age of 18 to participate in the ride.
The undersigned legal guardian for the minor passenger affirm their understanding and agreement to the Release, Consent, and Attest noted below on behalf of themselves and the minor participant.
NAME: Date:

Release: The undersigned (on my own behalf and on behalf of my heirs, personal representatives, successors and assigns), for and in consideration of Potomac Ministry Network , HonorBound Motorcycle Ministries (“HBMM”), General Council of the Assemblies of God, (“AG GC”), Assemblies of God US Missions (“AGUSM”), Assemblies of God Chaplaincy, Assemblies of God Men’s Ministries, Assemblies of God Motorcycle Chaplains, and any affiliated sponsors and contributors permitting me (or my child, who is under 18) to participate in Potomac Ride , and for other valuable consideration, the receipt and adequacy of which are hereby acknowledged, releases and discharges Potomac Ministry Newtwork , HBMM, AG GC, AGUSM, AG Chaplaincy, AG Men’s Ministries, and any affiliated sponsors and contributors, their respective officers, directors, employees, agents and districts from any and all claims and demands, rights and causes of action of any kind whatsoever which I (or my child) now have or later may have in any way resulting from or arising out of or in connection with my participation in the motorcycle ride or other related events. This Release extends to any and all claims I (or my child) have or may have against the released parties whether such claims result from negligence (except willful neglect) on the part of any or all of the released parties with respect to the motorcycle ride other events or with respect to the conditions (including but not limited to road, weather and traffic conditions), qualifications, instructions, rules, procedures and routes under which the motorcycle ride and other events are conducted, or from any other cause.

Consent: Consent is also hereby given to Potomac Men’s Ministries , HBMM, AG GC, AGUSM, AG Chaplaincy, AG Men’s Ministries, and any affiliated sponsors and contributors to use my (or my child’s) name, picture or portrait or likeness, audiotape or videotape recordings and sound or silent motion pictures of me (or those of my child) from this event in any media for editorial comment, educational, promotional and advertising purposes for the solicitation of contributions and for any other purpose in furtherance of the objectives of Potomac Ministry Network , HBMM, AG GC, AGUSM, AG Chaplaincy, AG Men’s Ministries, and any affiliated sponsors and contributors.

Attest: I am experienced in and familiar with the operation of motorcycles and fully understand the risks and dangers inherent in motorcycling.
I am voluntarily participating in the motorcycle ride and other events and I expressly agree to assume the entire risk of any accidents or personal injury, including death, which I might suffer as a result of my participation.

Send completed Registration and Fees to: Potomac Men’s Ministries, P.O. Box 690, Gainesville, VA 20156
Make checks or money orders payable to: Potomac Men’s Ministries In memo: HBMM (HonorBound Motorcycle Ministries)