| Registration |
 | |  | |  | |  | |  | |  |
| Lake Cumberland Powerboat Club, LLC Entry Form 2012 Lake Cumberland Thunder Run Poker Run June 22nd and 23rd SCHEDULE IS ON CENTRAL TIME Name: ____________________________________________ Phone: ___________________________________________ Address: __________________________________________ City: ________________________________________ State: _______________ Zip: __________________ Email: _______________________________________ Driver’s Name (1): ______________________________ Crew Name (2): ________________________________ Crew Name (3): ________________________________ Crew Name (4): ________________________________ ❑ $200-Entry Fee for Capitan, Boat & Navigator (Entry Fee includes: T-shirt, lunch, & dinner, for captain and navigator, also includes free 11x14 helicopter photo of your boat in action, 1-poker hand & slip at Grider Hill for the weekend) ❑ $50- Each Additional Crew Members ($50-Entry fee for addition crew members include: Lunch, dinner, and T-shirt). ❑ $50-Each Additional Poker hand Make of Boat: _________________________________ Boat Reg.#: _________________________________ Length: _________________________________ Boat Name: _________________________________ Power Type: Single___ Twin___ I/O___ O/B___ Engine make: _________________________ HP:___________ TOP MPH:________________ I certify that the above boat is insured for this event for Public Liability and Property Damage: Insurance Co: ______________________________________ Policy # ___________________________________________ Policy Expiration Date: _______________________________ Signature: _____________________________ In consideration of the Lake Cumberland Powerboat Club LLC accepting this application, the undersigned for myself, my heirs, executors, administrators, and assigns hereby release and agree to indemnify and hold harmless the Lake Cumberland Powerboat Club LLC, it’s sponsors, organizers, committee officials and each of their respective representatives, agents or employees from any claims, demands, damages, actions or causes of action arising out of or in consequence of any loss, injury, or damage to my person or property incurred from any cause whatsoever, in consequence of attendance or participation in the Poker Run event not withstanding that any such loss of injury or damage may have arisen by reason of negligence of the Lake Cumberland Powerboat Club LLC, its sponsors, organizers and committee officials or any of their agents. And the undersigned further agrees to hold said the Lake Cumberland Powerboat Club LLC, its sponsors, organizers and committee officials harmless and does hereby indemnify them from any and all liability for personal injury or property damage to third parties which may occur in any manner arising out of my attendance or participation in said Poker Run. The undersigned further acknowledges that the Poker Run is not a race and that speed in no way determines the outcome of the event and hereby agrees to abide to all the rules, directives, and conditions of the Poker Run, as set forth by the organizers, either verbally or in writing, before or during the Poker Run. The undersigned further agrees that the boat named in the application form is in safe operating condition and complies with and meets and is equipped with the prescribed equipment of the small vessels regulation of the Kentucky Water Patrol and US Coast Guard. Applicant Signature: __________________________________ Boat, Driver & Navigator $______________________________ Additional Crew Members $_____________________________ Total registrant and crew member fee’s made payable to Lake Cumberland Powerboat Club LLC: $____________________ Note: 10% discount if pre-registered by May 31, 2012. To pre-register, send entry form and check/money order to: Lake Cumberland Powerboat Club 864 White Tail Run Somerset, KY 42503 |
| Copy & Paste the above registration application |