Pcrf Poker Run

Riders Information

First Name Last Name

Address

City, State, Zip

Email Chapter

Uni-Sex Tshirt Size (circle one) XS S M L XL XXL

Passenger Information

First Name Last Name

Address

City, State, Zip

Email Chapter

Uni-Sex Tshirt Size (circle one) XS S M L XL XXL

Payment/Donation

¨ $ 40 Registration before 09/30 ¨ $ 20 second rider before 09/30

¨ $ 45 Registration after 10/1 ¨ $ 25 second rider after 10/1

I can not participate this year but I would like to donate:

¨ $25 ¨ $50 ¨ $100 ¨ Other

( ) To pay by Check –make check Payable to PCRF

( ) To pay by Credit Card

Total Amount enclosed or charged ______Check # ______

Credit Card # ______

Exp. Date ______CSV Code ______

Name on Card______Signature ______

Waiver and Release Form

In Consideration of my participation in the PCRF Poker Run 2010, I hereby agree, on behalf of myself, my family, my heirs, executors and/or assigns, that I assume all risks in connection with my participation including, but not limited to, any potential for injury, damage or harm and of any type or nature, whether to me, to my personal property, whether foreseen or unforeseen, that could potentially befall me. I understand and agree that PCRF and Sponsors, including their directors, officers, agents, representatives, employees as well as any of the cities, counties or municipalities through which the ride may take place (collectively “Released Parties”) may not be help liable or responsible in any way for injury, death, damage, or harm of any nature that I may sustain.

I have read, understand and agree to be bound by the above release and terms of participation.

Riders Signature

Co-Rider’s Signature

Inaugural Motorcycle

Poker Run

Non-Profit Event benefitting

Pediatric Cancer Research Foundation

Sunday, Oct. 24, 2010

Check in at 8:30 to 10:00 am

Ride begins at 10 at Irvine BMW- 9881 Research Dr, Irvine, CA 92618

BEST HAND WINS $1,000

· Vendors, Exhibits & Displays

· Free Lunch

· Opportunity Drawing

· Best/Worst Hand Prizes

· Chapter Challenge $250

· First 200 sign up’s receive free shirts

· Additional shirts will be for sale at $10

· Walk up registrations WELCOME

WWW.PCRF-KIDS.ORG/POKERRUN

Pediatric Cancer Research Foundation

9272 Jeronimo Road, Suite 107A,- Irvine, CA 92618

For questions call (949) 859-6312 or E-mail to