_____________________________________ to me know to be the identical person who signed the above Release and acknowledged the execution thereof to be their voluntary act and deed.
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| KEITH HANSEN MEMORIAL DEMOLITION DERBY RELEASE FORM | |||||||||||||||||||||||
| I __________________________________ hereby acknowledge that demolition derbys are dangerous activities and that participation as a competitor, and independent contractor, or a volunteer, exposes the participant to a substantial and serious risk of property damage, personal injury or death.� It is specifically acknowledged that participation in the Keith Hansen Memorial Demolition Derby will involve such a hazard.� Being fully aware that participation in the Keith Hansen Memorial Demolition Derby will expose me to substantial and serious risk of property damage and/or personal injury or death.� I hereby release the Deweese Community Club and property owners from liability for any and all property damage, personal injuries, or other claims which are known and unknown, foreseen and unforeseen, future or contingent.� I agree that I shall not now or at any time in the future, directly or indirectly, commence or prosecute any action, suit or other proceedings against the before mentioned arising out of or waived, released or discharged by me.� This release shall be binding upon spouse, my legal representatives, heirs, successors, assigns and me. | |||||||||||||||||||||||
| _______________________________________________________ | |||||||||||||||||||||||
| (Signature - Must be signed in front of a notary the day of the demo) | |||||||||||||||||||||||
| _______________________________________________________ | |||||||||||||||||||||||
| (Mailing Address) | |||||||||||||||||||||||
| ________________________________________________ | |||||||||||||||||||||||
| _______________________________________________________ | |||||||||||||||||||||||
| (YEAR AND MAKE OF CAR) | |||||||||||||||||||||||
| (City, State and Zip) | |||||||||||||||||||||||
| _______________________________________________________ | |||||||||||||||||||||||
| (E-mail Address) | |||||||||||||||||||||||
| -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | |||||||||||||||||||||||
| State of Nebraska | |||||||||||||||||||||||
| County of Clay | |||||||||||||||||||||||
| Now on this the ______day of August, 20___, before me, a NOTARY PUBLIC, in and for said state, personally appeared _____________________________________ to me know to be the identical person who signed the above Release and acknowledged the execution thereof to be their voluntary act and deed. |
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| Witness my hand and notarial seal on the day and year last above written. | |||||||||||||||||||||||
| _______________________________________________________�������� | |||||||||||||||||||||||
| (NOTARY PUBLIC) | |||||||||||||||||||||||
| Car #______�������������� Paid_______�������������������������������������� ���� ������������������������������������������������������������ | |||||||||||||||||||||||
| � | |||||||||||||||||||||||