38th Annual State Run

 

May 18, 19, 20, 2012 - Fredericksburg, Texas

 

**Open Thru 1972!**         ENTRY FORM     **Open Thru 1972!**

 

Please complete (print) and mail to:  Lone Star Street Rod Association

                                                              P.O. Box 54506 - Hurst, Texas 76054

                

Pre-Registration is $25.00 – Late Registration is $30.00

 

Non-members must include $20.00 for membership (optional for out-of-state entrants)

 

Pre-Registrations must be received prior to April 30, 2012.

All entries received prior to April 30, 2012 are eligible for a special drawing.

 

       Please make checks payable to Lone Star Street Rod Association

 

Name: ____________________________________________________________Age: _________

 

Spouse’s Name: _________________________ Children’s Name: _________________________

 

Mailing Address: _________________________________________________________________

 

City: ___________________________ State: ________________________ Zip: ______________

 

Phone: (_______) ______-________________ Miles Traveled:  ___________________________

 

Year of vehicle: 1 9_______Make: _______________ Model: _______________ Color: ________

 

Club Affiliations: __________________________________________________________________

 

Lone Star Member:  Yes or  No (LSSRA Number) ________________ Exp. Date: __________

 

Signature of Entrant: _______________________________________________________________

 

Legal Guardian if Under 18: _________________________________________________________

 

Liability:

In consideration of the acceptance of the right to participate entrants, participants and spectators by execution of this form release and discharge the Lone Star Street Rod Association, the City of Fredericksburg, the State of Texas, agents, representatives and anyone else connected with the management or presentation of the Lone Star Street Rod Association’s State Run of and from any and all known or unknown damaged, injuries, losses, judgments, and/or claims from any causes whatsoever that may be suffered by any entrants to his person or property. Further, each entrant expressly agrees to indemnity all of the foregoing entitles, firms, persons, bodies of and from any and all liability occasioned or resulting from the conduct of entrants or any participants assisting or cooperating with the entrant and under the direction of the entrant.

Membership                             For Office Use Only:                           State Run              

 

 [_] New ($20)   [_] Renew ($20)  [_] Non-Exp.   ****      [_] Pre-Register ($25)           [_] Late Register ($30)

                                                                                                                                        After April 30, 2012 

       YOU MUST BE A CURRENT MEMBER OF LSSRA UNLESS YOU ARE OUT OF STATE!