www.windycitypokerrun.com

Windy City Poker Run Entry Form for Cars

Step 1: Fill out form online 
Step 2: Print form
Step 3: Total Your Entry $$$
Step 4: Mail to Windy City Poker Run with payment (3860 Sunset Ave, Waukegan, IL  60087) or Fax it to us with Credit Card Information filled out to 847-625-8938

In consideration of Windy City Poker Run LLC accepting this application, the undersigned for myself, my heirs, executors, administrators, and assigns hereby release and agree to indemnify and hold harmless Windy City Poker Run LLC, its sponsors, organizers, committee officials and each of their respective representatives, agents or employees from any claim, demands, damages, actions or causes of action arising out of or in consequence of any loss, injury, or damage to my person or property incurred from any cause whatsoever, in consequence of attendance or participation in the Windy City Poker Run event notwithstanding that any such loss of injury or damage may have arisen by reason of the negligence of Windy City Poker Run LLC, its sponsors, organizers and committee officials harmless and does hereby indemnify them from any and all liability for personal injury or property damage to third parties which may occur in any manner arising out of my attendance or participation in said Poker Run. The undersigned further acknowledges that the Windy City Poker Run is not a race and that speed in no way determines the outcome of the event and hereby agrees to abide to all the rules, directives, and conditions of the Poker Run, as set forth by the organizers, either verbally or in writing, before or during the Windy City Poker Run. The undersigned further agrees that the vehicle named in the application form is in safe operating condition and complies with and meets and is equipped with the prescribed equipment necessary to operate by both Illinois and Wisconsin state laws and regulations.  I authorize for my credit card to be charged for the total amount below.

From
Subject
Name:
Address:
City:
State:
Zip Code:
Email Address for Verification:
Telephone:
Alternate Telephone:
Fax:
Entry Fee for Driver, Car, and One Passenger:
  
Additional Passengers Each ($75 per person):
License Plate #:
Model:
Engine:
HP:
CI/Ltr Displacement:
I certify the above car is insured for this event for Public Liability and Property Damage
Insurance Co:
Policy Number:
Expiration Date:
Name on Policy:
Drivers Name:
T-Shirt Size:
        
First Passenger:
T-Shirt Size:
        
Second Passenger:
T-Shirt Size:
        
Third Passenger:
T-Shirt Size:
        
Fourth Passenger:
T-Shirt Size:
        
Total amount payable $
Applicant Signature:
Would you be willing to provide car rides for Wish Kids and their families on Friday from 3pm-7pm?
    
Credit Card Type:
Credit Card Number:
Expiration:
3 or 4 Digit Security Code:
Billing Address (if different than above):

© 2005 Windy City Poker Run LLC