July 18th - July 21st, 2013
Registration Form  

Rider    :

Road Name  :

Passenger : 
( Or Spouse as 2nd Rider )
Road Name  :

Address: Address 2  :

City     : , State Zip Code

Telephone #:

EMail :

If an SCRC Member - What Chapter Name, # ?

Are you an officer ?
2nd 1st Asst State State Regional National BOD

NOTE: Dice Run includes 1 Patch and 1 Pin when registered before June 1st.
Everyone pre-registered ( by June 1st ) will receive a ticket for a chance to win a free night stay.

    Only select Extra Rally Patch or Extra Rally Pin if ordering Extras.    
NOTE: After June 1st T-Shirts, Patches, and Pins are available only at the Rally, while supplies last !
Ladies Tank Tops will NOT be available on site !
Save up to $10 per person by registering online now !



Quantity / Amount

Rider Registration for Dice Run
(includes 1 Patch and 1 Pin before June 1st )



Passenger Registration for Dice Run
( or Spouse as 2nd Rider )
(includes 1 Patch and 1 Pin before June 1st )



Extra 2013 GA SCRC Rally Patch



Extra 2013 GA SCRC Rally Pins



2013 GA Rally T-Shirt w/Pocket




2013 GA Rally Ladies Tank Top
( only available here online, not on site )




Any additional donation from your heart :


we're a simple web page, we need you to do the math here please       Total :


Proceeds Benefit St Jude Children's Research Hospital

Quantity of Patches, Pins and T-Shirts Available on site will Be Limitied!
Click HERE to see Shirt Color & Size Info

T-Shirts ( Specify Size & Color of each size needed )
How Many below "*" should match TShirt/Tank Top "*" sections above

How many T-Shirts ? Size & Color 1st Shirt Size & Color 2nd Shirt Size & Color 3rd Shirt Size & Color 4th Shirt
How many Ladies TankTops ? Size & Color 1st TankTop Size & Color 2nd TankTop Size & Color 3rd TankTop Size & Color 4th TankTop

To participate in 2013 Georgia State SCRC Rally,
you are required to fully read and sign the following waiver of liability.

Date: 01 February 2013 RELEASE AND WAIVER OF LIABILITY AND INDEMNITY AGREEMENT IN CONSIDERATION for being permitted to participate in the 2013 Georgia State SCRC Rally, benefitting St. Jude’s Children’s Hospital sponsored by the Southern Cruisers Riding Club at the Howard Johnson's in Commerce, GA the weekend of July 19th - July 22nd, 2013.

1. HEREBY RELEASE, WAIVE, DISCHARGE AND COVENANT NOT TO SUE The Southern Cruisers Riding Club, owners and lessees of premises used to conduct the event and each of them, their officers and employees, The State of Georgia, the dealers, officers, directors, management, officials and volunteers assisting in the event, the sanctioning organization or any subdivision thereof, grounds operators, grounds owner, officials, promoters, sponsors, advertisers; all for the purpose herein referred to as “releasees,” from all liability to the undersigned, their personal representatives, assigns, heirs, and next of kin for any and all loss or damage, and any claim or demands therefore on account of injury to the person or property or resulting in death of the undersigned, whether caused by the negligence of the releasees or otherwise while the undersigned is participating in the event;

2. HEREBY AGREE TO INDEMNIFY AND SAVE AND HOLD HARMLESS the releasees and each of them from any loss, liability, damage, or cost (including attorney’s fees) they may incur due to the presence of the undersigned participating in the event and whether caused by the negligence of the releasees or otherwise.

3. THE UNDERSIGNED PARTICIPANTS agree that while participating in this event, the use of alcohol or any substance which affects the ability to operate or control his or her vehicle or may be considered as hazardous to the health and safety of participants and spectators is strictly forbidden.

4. THE UNDERSIGNED AGREES that he or she will not use or operate any vehicle in violation or contravention of any City, County, State or Federal laws, statures, ordinances or regulation and shall be personally liable for all fines and penalties for traffic law violations.

5. HEREBY ASSUMES FULL RESPONSIBILITY FOR AND RISK OF BODILY INJURY, DEATH OR PROPERTY DAMAGE due to the negligence of releasees or otherwise while participating in the event. EACH OF THE UNDERSIGNED expressly acknowledges and agrees that the foregoing release, waiver, and indemnity agreement is intended to be as broad and inclusive as is permitted by law of the State in which it is operated in and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. By my electronic signature hereto, I acknowledge that I have read the above RELEASE AND WAIVER OF LIABILITY AND INDEMNITY AGREEMENT and that I concur in its entirety, and further agree that no oral representations, statements or inducements apart from the foregoing written agreement have been made.

Rider's Acknowledgement        * *

Passenger's Acknowledgement * *

Prior to pushing the "Submit Registration" button below:
You must type your name in the box above, exactly as it appears on your photo ID, as your electronic signature to the Release and Waiver of Liability and Indemnity Agreement.

I will make my payment by :     mailing my Check       or Online with Credit Card or Paypal

The submit registration button below will submit your registration information and
forward you to the Confirmation page where you can pay online now by Credit Card or Paypal.
You'll also find instructions there for mailing your payment by check.

You'll need to enter your Total $ from above as the 'donation' amount in the new window.

Did you verify Quantity, Size, and Color for the shirts ?

To print your registration before you submit it, click the PRINT button below :

( Don't forget to click the 'Submit Registration' too !)