SENECA COUNTY FAIRGROUNDS
DEMOLITION DERBY ENTRY FORM
Saturday, July 28, 2012
ENTRANTíS NAME ____________________________________________ AGE ___________
STREET ADDRESS ______________________________________ PHONE _______________
CITY _________________________________ STATE _______________ ZIP ____________
CAR/YEAR/MAKE ________________________________ SPONSOR ___________________
Complete this form and return with entry fee. Pre-entry fee $35.00 if paid before day of show.
Entries made day of derby will be $50.00. All entries includes drivers pit pass. Cash or money order
made out to: SENECA COUNTY AGRICULTURAL SOCIETY. (NO ENTRY FEE WILL BE REFUNDED!)
I have read the rules and accept the decision of the Derby Judges as final and elect to use the ground/track in its prescribed condition. I hereby expressly release both the producer and sponsor and all of their associates for any injuries of any kind or nature which may occur or be received of said participation in said Derby contest. And I hereby expressly waive all claim for injuries that may occur should said participant be injured while being a contestant in said Derby contest.
SIGNED ______________________________________ DATE _______________________
Each driver must be 18 years of age and have a valid Driverís License. Drivers under 18 years of age must show proof of a valid Driverís License and a notarized release signed by a parent or guardian.
STATE OF _______________________ COUNTY OF ________________________________
Being the parent and/or legal guardian of _____________________________ hereby consent _______________________ to enter and/or participate in the Demolition Derby being held at SENECA COUNTY FAIRGROUNDS and that said ____________________________________ is a minor and under the age of 18 namely: age ______, and that I hereby expressly release both the producer and sponsor and all the associates for any injuries of any kind or nature which may occur or be received as a result of said minorís participation in said derby. I hereby waive all claim for all injuries which may occuróshould minor be injured or killed while being a contestant in said contest.
Parent and/or legal guardian: ____________________________________________________
Subscribed and sworn this ____________ day of ____________________ A.D. 2012
Notary Public _______________________________ County of_________________________
My Commission Expires: _______________________________