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Passenger Name:
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Please send these details and a registration fee of $15.00 per person to Jimbo Moddrell Rally and Run, 1427 S. 4th Chickasha, OK 73018. Make checks Payable to Jimbo Moddrell Rally and Run.
Rider Name:
Address, City, State, ZIP Code:
Phone and Email Address:
Rider Signature:
Passenger Name:
Address, City, State, ZIP Code:
Phone and Email Address:
Passenger Signature:
Rider and Passenger do hereby hold harmless Jimbo Moddrell Rally & Run of any loss, damage, injury , claims of action , or payment resulting from direct or indirect participation in this even, including but not limited to, the cost of defending any said claims or cause of action including attorneys fees. Rider and passenger agree to obey all applicable federal, state laws and local ordinances during their participation directly or indirectly in this event. Rider and passenger do herby release Jimbo Moddrell Rally & Run of and from any loss, damage, injury, claims, or causes of action associated with participation directly or indirectly, including losses occurring from negligence during this event.