STAR Touring & Riding Association
S.T.A.R.
of
2011 Motorcycle Waiver =
and
Release Form
__________________________________
In sig=
ning
this document, I represent that I am fully knowledgeable of the dangers and
hazards associated with riding motorcycles. I understand that such activiti=
es may cause serious injury or death<=
/u>. 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 harml=
ess,
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 Yamah=
a,
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 tour=
ing
by motorcycle.
I cert=
ify
that I have no known physical or mental impairment that may affect my safet=
y 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 th=
at
may impair my understanding or judgment and that I will not at any time dur=
ing
the tour operate my motorcycle under the influence of any narcotic, alcohol=
or
any drug. I also understand that t=
his
Waiver and Release is in force until December 31, 2011 and covers any and a=
ll
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 ride=
rs
are licensed. A Chapter officer must verify the Motorcycle Endorsement of e=
ach
member.
Motorcycle
Endorsement Verified YES___ NO ___
Verified
by: ___________________
Title: ________________________________