STAR Touring & Riding Association
S.T.A.R. of
2010 Motorcycle Waiver
and Release Form
__________________________________
In
signing this document, I represent that I am fully knowledgeable of the dangers
and hazards associated with riding motorcycles. I understand that such
activities may cause
serious injury or death. I certify
that I am duly licensed and competent to operate a motorcycle in a safe manner,
and the vehicle is in a safe operating condition. I will be riding on public
highways and am solely responsible to determine the speed and operational
characteristics of my motorcycle while participating in the tour. I hereby
release and hold harmless, STAR Touring and Riding and any of its executives or
members, Star Touring and Riding, Chapter 206 and any of its executives or
members, and Stadium Yamaha, and any of its executives or members, against any
and all claims, causes of action, or any other liability of any kind arising
from my activity of touring by motorcycle.
I
certify that I have no known physical or mental impairment that may affect my
safety or the safety of the group. I understand that the choice of wearing a
helmet or other protective gear is solely my own and that I am responsible for
my compliance with all state laws, including those regarding helmets. I certify
that I am not under the influence of any narcotic, alcohol or other drug that
may impair my understanding or judgment and that I will not at any time during
the tour operate my motorcycle under the influence of any narcotic, alcohol or
any drug. I also
understand that this Waiver and Release is in force until December 31,
2010 and covers any and all activities.
Signature_________________________________________Date__________________
Name
(print)______________________________________ Phone #( )
__________
Drivers’
license number
Vehicle
Insurance carrier ______________________ Policy # _____________________
Signature
of Passenger______________________________ Date __________________
Passenger
Name (print)___________________________________
Witness
Signature________________________ Witness Name (print)________________
The following information is VOLUNTARY
and is used for emergency purposes only:
Emergency
contact person___________________________________________________
Relation_________
Phone (home)___________(work)____________ (cell)
____________
Health
insurance carrier (rider)___________________________
Policy#_______________
Health
insurance carrier (passenger)______________________
Policy#_______________
List
any allergies, medicines taken regularly, or medical
conditions____________________
_________________________________________________________________________
FOR OFFICIAL (CHAPTER) USE ONLY:
The Motorcycle Safety
Foundation estimates that only 40% of all motorcycle riders are licensed. A
Chapter officer must verify the Motorcycle Endorsement of each member.
Motorcycle Endorsement
Verified YES___ NO
___
Verified by: ___________________ Title: ________________________________