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