L. I. Cruizin’ for a Cure 2010

A 501C3 Charity. Donations are tax deductible. Consult your tax advisor for specifics

with Assistance from Still Cruisin Car Club of Sayville

Capital One Bank   275 Broadhollow Road    MelvilleN.Y.    L.I  Expressway Exit 49 North/ Route 110 

Sunday September 12^th, 2010 (no rain date)   9:00-3:00   Gates open at 7:00

Proceeds go to free Prostate Cancer testing and education on Long Island

Entry Fee (prior to September 3^rd) $20.00       Entry fee Day of Show $25.00   

Goody bag for first 200 pre-registered; all exhibitors receive an event tee shirt while supplies last

Shirt size:  Medium___  Large___   Xlarge___  XXLarge___   XXXLarge___    Prostate Cancer Survivor? Yes__ No___

Make checks payable to LICruizin   Mail complete form and check to   LICruizin   PO Box 604  Jericho, NY11753
Want to make an additional donation? Add on to check or make separate check payable to LICruizin, mail to address above

Print Legibly  One form per car - must be completely filled out and release must be signed below for admission to the show
Name _____________________________________ Phone Number (____) ________________

Address ___________________________  City_____________________ State ____  Zip_____
Car Make _________________________Model _______________________ Year __________

Club Affiliation ____________________________Email________________________________

Questions? 888-LICRUIZ    info@licruizinforacure.com    www.licruizinforacure.com  

ASSUMPTION OF RISK  I understand that I, and each participant in the Event, will be engaging in activities that may involve the risk of serious personal injury, illness, permanent disability, dismemberment and death, that also involve the risk of severe economic and property loss and damage. I understand that these risks may result from the actions, negligence and failure to act of myself and others (including but not limited to other participants in, and the organizers and volunteers of the Event) and the condition of any property, facilities or equipment used. I also understand that there may be risks involved which are not known to me or CLK-HP 275 Broadhollow LLC, the organizers and volunteers (if any) and may not be foreseen or reasonably foreseeable by any of us at the time of the activities in which I may participate.

                I assume all of the foregoing risks including the risk of any negligence by other participants or by any of the organizers or volunteers of the Event and their respective owners, partners, directors, officers, employees or agents, and the risk of injury caused by the condition of any property, facilities or equipment used during the Event, and accept personal responsibility for any injury (including but not limited to personal injury, disability, dismemberment and death), illness, damage, loss, claim, liability or expense of any kind or nature, that I or any property may suffer arising out of or in connection with the Event or my participation therein or attendance thereat.

LIABILITY RELEASE AND INDEMNITY AGREEMENT   I  hereby  by release and forever discharge and agree to save and hold harmless  CLK-HP 275 Broadhollow LLC, CLK/HP LLC, its managing agent,  and each of their respective parents affiliated and subsidiary companies, volunteers associated or affiliated with the Event, the respective organizers of the Event and each of their respective officials, owners, partners, directors, officers, employees and agents, and the other participants in the Event (each such entity or individual being referred to as a “Released Party”) of and from any and all injuries (including personal injury, disability, dismemberment and death), illness losses, damages, claims, liabilities, or expenses of any kind or nature (and whether accruing to me, my heirs or my personal representatives) that are caused or alleged to be caused in whole or in part by the action, negligence , failure to act or condition of the property, facilities or equipment of any Released Party and that arise out of in connection with the Event or my participation therein or attendance thereat.

SEVERABILITY             I agree that the foregoing agreements are intended to be as broad and inclusive as is permitted by law. Any provisions herein found by a court to be void or unenforceable shall not affect the validity or enforceability of any other provision.

Signature_________________________Print Name _______________________Date _____