I, ______________________________, the undersigned, agree that I am providing my own

insurance for this ride and that I accept full responsibility for myself and my passenger, if any.

I agree that I will not hold the organizer(s) of this ride responsible for anything involved with

this ride that is beyond their control.


                                    Dated: _______________________________________

Please mail this form to:

    Leland C. Sheppard
    3251 Ken Derek Lane
    Placerville, CA 95667

(NOTE: This form is requested only once. If you have sent one in from a previous year, you do NOT need to send one in again. Thanks.)

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