Jerry and Phyllis Rose (10792-L)

7 Berwick Ct

Miamisburg OH  45342

937-866-1752

Ohio State Rally

WATCH THIS SITE FOR THE 2012 OHIO STATE RALLY

Reservation deadline: 

Please send signed registration/disclaimer form below and check payable to:

Phyllis Rose

7 Berwick Ct

Miamisburg OH  45342

Additional information or prosecook@woh.rr.com

Name: ___________________________________________________Klub #________________

                      His                      Her                          Last

Address:_______________________________________________First Rally?______________

City:_____________________State:_________Zip:____________Phone:__________________

Cell:___________________________Email:__________________________________________

Guest(s)_______________________________________________________________________

Handicapped?#________Diabetic?#________Golf#?___________Early Arrival_________

                                                                                              Total Enclosed:__________________

The published Regional Rally Cancellation Policy Applies!

Disclaimer:  All persons attending a Klub rally must sign this disclaimer in order to participate.

I agree, in consideration for being able to participate in this Newmar Kountry Klub activity, to release and to indemnify and

hold harmless Newmar Kountry Klub and Newmar Corporation, it’s directors, officers and employees, from all liability for injury or damages to my person or property, or the property of persons who accompany me to this activity.  With knowledge of the type of risk or harm, which might occur at such activity, I sign this release and indemnity as part of my application.

All adult members and their guests must sign and in so doing, assume all responsibility for minors in their care.

Signature: _________________________________________ Signature: _____________________________________________

Signature: _________________________________________ Signature: _____________________________________________