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GENERAL INFORMATION
GC.com ScreenName ____________________________ Name _______________________________________ Address _____________________________________ City ________________________________________ State/Zip ____________________________________ Date of Birth __________/___________/________	Drivers License # ______________________________ State /Expiration Date ___________________________ Cell Phone ___________________________________ Home Phone __________________________________ Work Phone __________________________________ Email _______________________________________

EMERGENCY INFORMATION
In Case of Emergency - Contact Name _____________________________________ Phone Number ______________________________	Medical Information We Need To Know: ____________________________________________ ____________________________________________

Release of Liability, Declaration & Agreement: Release:I hereby release and agree to hold harmless the Great Basin and Eastern Sierra (GBES), the Bureau of Land Management (BLM), the State & Counties of Nevada, the owners and lessees of the premises, and the officers, directors, members, volunteers, officials, participants, sponsors, promoters, contractors, representatives, agents and employees of all of them, of and from any and all liability, loss, claims and demands that may accrue from any loss, damage or injury, including death, loss of limbs and permanent disablement, to any person or property, in any way resulting from or arising in connection with my actions while involved with or participating in the event and whether arising while engaged in competition or in practice or preparation therefore, or while upon, entering or departing from said premises, from any cause whatsoever. Declaration: I declare that I know the risk and danger to myself, all other persons, and property while participating or assisting in the event, so voluntarily and in reliance upon my own judgment and ability, I hereby assume all risk whatsoever. I also agree that any legal action or threat of such, I will be liable for all costs, including but not limited to attorney and court costs of the promoters. Agreement:By my signature below, I hereby agree to the terms of the above release, attest to my declaration, and further agree to abide by the rules and regulations, which govern this event.

Participants Signature ____________________________________________ Date _________________

Parent / Guardian Signature ________________________________________ Date _________________