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.
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.)