Moving Violation Motorcycle Club of Boston, Inc.

Emergency Information Form and Statement of Release

 

Rider's Name:                                                                                                                     

Address:                                             City:                          State: Zip:            

Telephone:                                                     

Person to Notify:                                                                                                                 

Address:                                             City:                          State: Zip:            

Telephone:                                                     

Health Insurance Carrier:                                                                                                 

Policy #:                                                          Blood type:                                                  

 

Please list any known allergies:

 

 

What medications are you currently taking?

 

 

Other significant medical information:

 

 

 

If you are carrying a passenger, please check here            AND list the passenger's name below. *Your passenger must also complete a copy of this Emergency Form.

PassengerŐs Name:                                                                                                               

 

statement of release

 

The undersigned participant of The Moving Violations Motorcycle Club, Inc.'s annual Benefit Run, which takes place May 13, 2017, does hereby agree to the following provisions:

 

That the participant releases the Moving Violations board members, and MVMC, Inc, from liability for loss, damage, cost, claim, judgement, or settlement with regard to any accident or injury (including but not limited to bodily injury and property damage) arising out of participation in the aforementioned Benefit Run.

 

Your Signature:                                                                                Date:                         

 

Print Name:                                                                                      

*All information provided will be held in absolute confidence.

These forms will be destroyed after the event has ended. *