Heartland Pyrotechnics Association, Inc

Midwest Fireworks Festival 3

Registration Form – 2007October 5 and 6, 2007

(Note: If you are 18yrs. of age and older, you need to fill out your own form.)

You must be a current member of a fireworks club or organization to attend. Each shooter’s fee, vendor registration is $50.00; at least one $50.00 paid member (primary) is required to shoot fireworks in a family group. You must be 21 years of age or older to shoot class B material. You must be 18 yrs. and older to attend without an adult. Absolutely no manufacture of any type of flash powder is allowed!

Name: ______Current Member of: ______, ______

Address: ______Date of Birth: ______

City: ______State: ______Zip Code: ______

Phone (optional): ______Number in Party: ______

E-Mail: Associated with what Member:

Registration Fees

Note: You must be 21 yrs. of age or older to shoot class B items.

(At least one $50.00 paid member is required in a family or group to shoot fireworks.)

Primary Family Member(Adults 18 yrs. or older)$50.00.…X ______$ ______

Spouse or Child of Primary (Adults 18 yrs. or older) $15.00 …X ______$ ______

Onsite Camping($11 per Day )$11.00 …X ______$ ______

Tables Number required _____ X $8.00 = $ ______

TOTAL ……………….…………… $ ______

Print Names:

Additional Adult 18 yrs. & older:______, ______

Junior:______, ______, ______

Vendors

There is no additional fee for vending. HPA is renting tables for your convenience. A fee of $8.00/per-table is required if you wish to rent them. We will have limited tables, please reserve yours now.

To pre-register, please send registration forms to:Kevin Murphy, HPA Treasurer, 2721 Benjamin Dr, Wonder Lake, IL 60097 NOTE: Only fully completed forms will be accepted. Signature is required on the reverse side of the application.

Heartland Pyrotechnics Association, Inc.

WAIVER OF LIABILITY AND ASSUMPTION OF RISK

Please read carefully before signing!

The registrant undersigned, and individuals listed below, hereby agree to waive any and all liability resulting from any accident, any negligence, any misuse, any type of participation either directly or indirectly with fireworks, pyrotechnics, or related items and activities, with respect to the owner of the land in which the fireworks and related items are to be used, demonstrated, manufactured, sold, bought, displayed, or destroyed by the Heartland Pyrotechnics Association Inc., its members, officers, agents, employees, successors or licensees, any operator, any permit holder, any event vendor, or any instructor of or for fireworks use, public or private displays, demonstrations, competitions, sales or purchases of fireworks or fireworks related materials of any type, or any other pyrotechnic related activity. This waiver of liability goes to any intentional or negligent act that may be performed by the above, operator of a public or private display, demonstration, use of, owner of the land in which the fireworks are to be used, associated parties or Heartland Pyrotechnics Association Inc. member(s).

The registrant undersigned, and individuals listed below, agree to abide by all safety rules and conduct guidelines. It is expressly understood that any violation, deviation, failure to obey and follow said rules, guidelines, by registrant undersigned or listed below, is cause for the immediate suspension of Midwest Fireworks Festival & Heartland Pyrotechnics Association Inc., privileges, immediate revocation of membership and immediate expulsion from the site, without any right to return, upon which said Midwest Fireworks Festival & Heartland Pyrotechnics Association Inc., activities are being held.

The registrant undersigned, expressly states, that they are the parent or guardian for any minor(s) listed below and agree that all terms of the foregoing Waiver of Liability applies to said minors.

The registrant undersigned, and individuals listed below understand that pyrotechnic materials are and will be used at Midwest Fireworks Festival & Heartland Pyrotechnics Association Inc., events, and that a risk is associated with the use of pyrotechnic material, even if the pyrotechnic material is handled in an appropriate manner and all applicable safety rules and guidelines are followed. The registrant undersigned and listed below understands the risk associated with pyrotechnic materials and voluntarily assumes said risk associated with the use of pyrotechnic materials at Midwest Fireworks Festival & Heartland Pyrotechnics Association Inc., events.

I hereby state that I have read the foregoing Waiver of Liability and Assumption of Risk, and will agree to abide by all its terms. I the undersigned, certify that all information provided in the application is true.

Date: ______, 2007.

1. Adult Signed: ______Printed: ______

2. Adult Signed: ______Printed: ______

Minors: ______, ______,