RIDE FOR LIFE POKER RUN May 18th, 2013 Registration Form Proceeds benefit Relay for Life

and Walleye Rodeo Driver Name: ______________________Shirt Size________ Phone #: ___________ Address: ______________________ City/State: ___________ Zip ________ Email: _______________________________________________________ Passenger Name: ___________________Shirt Size_________ Phone #: ___________ Registration from 8:30 am to 10:00 am at One stop on west side of Canton,Ok Riders meeting 9:45am at One stop. First Bike out at 10:00 am Last Bike in at 3:00 pm Winners announced at 4:30 pm at the PigNic cook off feed. (MUST BE PRESENT TO RECEIVE AWARDS) Please check all that apply: _____ $ 25.00 for First Hand Poker Hand Per Bike _____ $ 20.00 x _____ Number of Poker Hands (No maximum) _____ $ 15.00 for T-shirt (circle one) (S M L XL XXL 3XL 4XL other_____)) _____ $ 10.00 to Just Ride _____ Total Fee (Staff please initial for payment recd) DISCOUNT TO THE CONCERT WITH ENTRY!!! Make Checks payable to Relay for Life . Please visit us for Canton Walleye Rodeo Celebration May 16th-19th 2013 ***For more information, contact Kenneth Daykin at (580)-554-0606*** Send completed forms and payment to: Raelene Castillo Rt 1 box 122a Longdale,Ok 73755 You must read and sign the following Disclaimer/ Waiver: I, the undersigned participant, on behalf of myself, may heirs, legates and assigns, hereby agree to indemnify, save and hold harmless the City of Canton and Relay For Life or any of their agents, representatives, employees or assigns, for my health, safety or injury and or disability arising out of or resulting from participation in this program. Signature: _______________________________________________ Date: ______________ _______________________________________________ Date: ______________