Seacoast Dirtbike Tours
197 Woodlawn Circle
Portsmouth, NH 03801
603-436-4331
303-775-8895
Registration Form
NAME: __________________________________________________________
ADDRESS: STREET______________________________________________
CITY__________________________________ STATE______ ZIP CODE___________
PHONE: HOME________________ CELL______________
E-MAIL: __________________________
AGE: _______ SEX: MALE____ FEMALE____
ABILITY LEVEL: NOVICE___ AMATEUR___ EXPERT___
BIKE: MAKE__________ MODEL___________ CC______
PLATE NUMBER: __________________
TOUR NUMBER: ___________________
TOUR DATE: _______________________
MEDICAL INSURANCE? YES___ NO____
POLICY NUMBER: ________________________
EMERGENCY CONTACT: NAME___________________PHONE___________
HAVE OWN DIRTBIKE? YES___ NO___
TRANSPORTING YOUR OWN DIRTBIKE? YES____ NO____
ANY MEDICAL CONDITIONS? EXPLAIN.
Total Cost of Tour: $____________________ Deposit (50%) : $ _____________________
Method of payment: Visa___ MasterCard___ Check____
Credit Card #__________________________________ Exp. Month ____ Year _____
I, the undersigned, hereby agree, in participating in our tours, to forever release and discharge Seacoast Dirtbike Tours, Seacoast Guided Dirtbike Tours and any of its owners, subcontractors, or employees, all other participants, all persons whose property the tour may pass, from any and all loss, injury, death, expense, damage, cause of action, or any claim whatsoever, which I may suffer or sustain, or which may arise out of or in connection with the tour and my participation therein. I declare that I am competent to ride in this tour and do so with full knowledge of the dangerous nature of participation and its inherent risk of physical injury.
Signature_______________________________________________ Date: _______________