*All fields must be completed

Were you referred to this program by an authorized KYMCO USA dealership?  Yes     No

First Name:      

Last Name:      

Social Security Number:      

Address 1:      

Address 2:

City:      

State:      

Zip:      

Phone:      

Date of Birth:      

Email Address:

VIN:      

VIN:      

VIN:      

Riding #:

Classes:

Series GNCC Only:

Riding as Amateur Only:

RELEASE, LIABILITY WAIVER, INDEMINIFICATION AND ASSUMPTION OF RISK ("Release") ATV Racing Could Cause Serious Injury

SECTION 1
In consideration of being eligible to participate in the Program, I, the undersigned, for myself and for my successors, heirs and assigns, release, waive liability, promise never to sue, and forever discharge, KYMCO U.S.A and its affiliated companies, and each of their subsidiaries, agents, representatives, employees, dealers, servants, officers, directors, and shareholders (collectively , "Released Parties) from all claims, including but not limited to claims for negligent acts or omissions, actions or judgments that I may have or claim to have against Released Parties, or any of them, for ALL PERSONAL INJURIES, INCLUDING DEATH, AND ALL INJURIES TO PROPERTY, real or personal, directly or indirectly caused by or arising out of my participation in the Program.

I understand that ATV riding is inherently dangerous. I represent to KYMCO U.S.A that I have had sufficient experience riding ATVs to understand all the risks involved in ATV racing. I understand all the risks involved in ATV racing. I expressly and voluntarily assume all risk of personal injury or death sustained while participating in racing events and the Program, whether or not caused by the negligence or other fault of Released Parties, or any of them, including but not limited to, EQUIPMENT MALFUNCTION FROM WHATEVER CAUSE, INADEQUATE TRAINING OR SUPERVISION, DEFECTIVE DESIGN OR MANUFACTURE OF EQUIPMENT OR ATV RACE COURSE, FAILURE TO KEEP SAFE, FAILURE TO INVESTIGATE OR SUPERVISE OTHERS, OR FAILURE TO WARN OF POTENTIAL RISKS.

I further agree, for myself and for my successors, heirs and assigns, to indemnify, defend and hold harmless all of the Released Parties from all claims and suits for personal injuries, including death, and damage to property, caused directly or indirectly by any act or omission arising out of my participation in the Program. I further agree that all photographs, pictures, slides, likenesses, and/or movies taken or made of me by or for KYMCO U.S.A in connection with my participation in the Program, or any reproduction or replica of the same as well as my name may be used in any manner by KYMCO U.S.A or by any person or entity authorized by KYMCO U.S.A. I am in good health and have no physical condition that would restrict or prevent me from participation in this Program.

I understand that I am giving up substantial rights by agreeing to this document. I agree to abide by the guidelines and “Official Rules” of the Program. A complete list of guidelines and official rules are listed on the KYMCO USA website.

I agree to the terms listed above

2. PARTICIPATION BY MINORS: (This section must be completed if the rider is under 18 years old or considered to be a minor in your state)

I certify that the above rider is my minor child and that:
I represent and warrant to KYMCO U.S.A and certify, acknowledge and agree as follows: (a) the above rider ("Child") is a minor, (b) I am the parent or legal guardian with custody of the Child, (c) the Child and I reside at the same address, (d) I am the owner of all ATVs identified above by their 17-digit Vehicle Identification Number, (e) either the Child is listed or I am listed as the owner of such ATV on the KYMCO U.S.A warranty-sales registration, and (f) I understand that KYMCO U.S.A is relying on each of the foregoing representations and warranties to permit the Child to participate in the Program. Only one (1) person per vehicle may earn KYMCO Contingency monies. All KYMCO USA  will be paid via check 10-14 days after confirmation of race class event winners.

SECTION 2

PARENTAL CONSENT, RELEASE, LIABILITY WAIVER AND INDEMNIFICATION
I hereby certify that I am the parent or legal guardian of the above Child and that I have read Section 1 of this Release. I understand that for my Child to participate in the Program, I hereby consent to the Child's participation in the Program and agree, on behalf of the Child, myself and both of the Child's parents to release the Released Parties and waive liability from all claims, including without limitation claims for negligent acts or omissions, arising directly or indirectly from or related to the Child's participation in the Program. I agree that the Child and I will be bound by all of the terms listed in Section 1 and 2 of this Release.

I understand that there are risks (including SERIOUS BODILY INJURY OR DEATH) associated with participating in the Program, and I hereby assume, on behalf of the Child, myself and both of the Child's parents, all such risks, including without limitation those detailed above. I am releasing any and all claims that the Child's parents or I may have for emotional distress or loss of consortium in the event the Child suffers bodily injury or death. I further agree, for myself, for both of the Child's parents, and for all of our respective successors, heirs and assigns, to indemnify, defend and hold harmless the Released Parties, and each of them, from all claims and suits from personal injuries, including death, and damage to property, caused directly or indirectly by any act or omission arising out of the Child's participation in the Program, and from all judgments recovered and from all expenses incurred in defending said claims or suits.

I understand that I am giving up substantial rights by agreeing to this document.

I agree to the terms listed above

3. SPONSORED RIDER AFFIDAVIT

My ATV is a Dealer Sponsored ATV

I am riding a vehicle that is sponsored by a KYMCO USA dealer. Listed below is the dealership information. I agree that no other rider shall be entitled to any contingency rewards from KYMCO U.S.A by riding the vehicles sponsored by the following dealer.

Dealership/Owner's Name:

Dealer Phone:

Owner's Address:

Owner's City:

Owner's State:

Owner's Zip:

Participation Agreement

By submitting this Enrollment Form, the participant certifies that the information contained above is true and correct, and the participant verifies that he or she is at least 18 years of age and agrees to abide by the above terms. Incomplete forms will not be processed.

I agree    I disagree