Come join the fun and support GDA! Raffle prizes! Poker Run $500.00 purse High Hand $200 2nd Place $100 Low Hand $200 Free food at the end of the run! Saturday, August 26, 2017, 7:30 a.m. First ride out 8:00 a.m. - Last ride out 9:00 a.m. Starts at District W24 Hall 25 Cornell Ave., Gladstone, OR Each rider and passenger will receive an event t-shirt Pre-registration must be received by August 20, 2012 at: IAM&AW Local 63 25 Cornell Ave Gladstone, OR 97027 Registration: $35.00 Donation per rider, $10.00 per passenger Please make checks payable to Local 63 Guide Dog Dash Pre-registration is appreciated ALL PROCEEDS BENEFIT GUIDE DOGS OF AMERICA Registration (Please Print) Name (Rider):____________________________________________ Age_______ Address ________________________________ Telephone (____) __________ City, State/Province, Zip Code ________________________________________ Motorcycle: Make ____________________ Model __________ Year ______ LIC#________ Name (Passenger):_______________________________________ Age _______ Address _________________________________Telephone (____) __________ I understand that state law requires vehicles and drivers/riders to be appropriately licensed and endorsed and to have their own liability insurance to operate on state roads and highways and that it is my responsibility to provide that insurance. I, therefore, release and hold harmless IAM&AW District W24, Local 63 Guide Dogs of America event volunteers, sponsors/supporters, participating merchants and event site owners and personnel from any responsibility for any damage or injury I may incur or cause while participating in this event. I have read this form and agree to the above statement (Signature required). __________________________________________ ______________________________________ Rider Signature Date Co-Rider/Passenger Signature Date Shirt Size_______ Shirt Size_______