Please complete the registration form for the upcoming 2010 Country Tractor Run to be held June 26, 2010. Bring a friend and join us for a day which offers the opportunity to have fun and help the kids at Make-A-Wish. Kids need angels like you! Registration is limited to the first 250 paid registrations, so don't delay sign up today. A waiting list will be created.
The registration fee is $30.00 per driver. Your registration fee will include a free T-shirt, 2 (two) tickets for the evening meal, and a participation certificate, complete with a photo of you with your tractor. All proceeds go to benefit Make-A-Wish of South Dakota. DVD's of the run are going to be made available for a cost of $20 which can be included with your registration fee.
We look forward to seeing you in June 26, 2010!!
Please print a copy of the form below and send it along with your registration fee. Be sure to include your e-mail address if possible.
*Your Name: (last, first)
____________________________________________________
Name to appear on NAME-TAG
____________________________________________
*Address:
_______________________________________________________________
City/State/Zip:
___________________________________________________________
Phone #: _______________________________________________________________
Emergency Contact Phone #
________________________________________________
E-Mail address:
__________________________________________________________
Physician's Name:
________________________________________________________
Phone # ________________________________________________________________
Medical Conditions:
_______________________________________________________
*Tractor Year:
____________________________________________________________
*Tractor Make:
___________________________________________________________
*Tractor Model:
___________________________________________________________
*T-shirt size: ______________________________________________________________
*Your Signature:
___________________________________________________________
Make checks payable to: Country Tractor Run, 101 Elevator Street, New Effington, South Dakota 57255
Country Tractor Run
New Effington, SD
RELEASE AGREEMENT
The underlying undersigned, on behalf of himself/herself, their heirs, executors, successors, assigns, or personal representatives, do fully and completely release the organizers, benefactors, sponsors, promoters, and/or their heirs, executors, successors, assigns, or personal representatives from any and all damages of any kind, be they financial, personal injury, or sots of any kind and of any nature regarding the event commonly referred to as the "Country Tractor Run", regardless of what art of the event in which I participate, and which includes my going to/coming to/from the event.
The undersigned affirms that he/she is an adult, or legal and and of sound mind, and further release any and all derivative claims that may result of any claims I may have, such as loss or spousal of child consortium or any other similar or related claims as a result or any injuries or losses that may occur.
I recognize that I am fully and completely individually responsible for anything that may occur related to or during the "Country Tractor Run." The undersigned agrees to fully hold harmless and indemnify the heirs, successors, assigns, or personal representatives for all costs, including reasonable attorney fees, for any breach of this agreement.
This release/hold harmless/indemnification agreement is freely and voluntarily executed by the undersigned and after being apprised if all relevant information and having a thorough opportunity to have this document reviewed.
Dated this __________ Day of ___________ 20___
SIGNATURE:
WITNESS:
____________________________________
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