Registration Form:

Registration Application  

I’d like to show my wheels for Prostate cancer.

I will be showing a: _________________________________________

                                                Type of Wheel

Sorry, I cannot participate, but I would like to support Wheels for Prostate Cancer and wish to make a donation of

$_____________ (enclosed).   DO NOT SEND CASH

(Please print)

Name      ____________________________________________

Address ______________________________________

City, State, Zip      ________________________________

Phone Number      ________________________________

E-Mail                    ______________________________________

Check In Time: 9:00 A.M. – 11:00 A.M. Show from 11:00am to 3:00pm

Wheels are requested to stay on the field until 3:00 pm

Entry Fees:

$20 per vehicle pre-registration                       $25 meet-day registration

Payment: Make checks payable to Wheels for Prostate Cancer Research (WFPCR) and mail with registration form to: WFPCR  P.O. Box 65086   Baltimore, MD 21209 (Questions-- 410-486-2959). On memo line of check, please state: Wheels for Prostate Cancer.

Please do not send cash via mail.

Pre-registration forms must be received no later than September 10, 2011.

Signed waiver and release required for all participants. All “Wheels” must have Liability insurance.

Liability Release. In consideration of my entry, I, for myself, my executors, administrators, and assignees do hereby release and discharge WfPCR and The Fire Museum of Maryland, all sponsors, coordinators and all other organizers and volunteers of all claims of negligence, injuries, damages, demands, and/or actions whatsoever, in any manner, arising from my participation in this event.

Signature of Participant                                            Date

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