Haven of Portage County's 2021 Road Rally

ROAD RALLY REGISTRATION FORM
DRIVER NAME
PHONE
STREET ADDRESS
CITY
ZIP
Email address
example@example.com
NAVIGATOR NAME
PHONE
STREET ADDRESS
CITY
ZIP
VEHICLE (MAKE & MODEL)
LICENSE PLATE#
In consideration of the acceptance and permission to participate as an entrant of the road rally on February 20, 2021, I hereby waive and release The Haven of Portage County and their respective Officers, directors, executive and members as well as all sponsors from and against all claims for damages, bodily injury or any other costs incurred which are caused by or arises from participation of the applicant herein during any program or in any facility on any location where a program is being considered. Team drivers must have a valid driver's license and carry proof of insurance at all times during event.
Driver Signature

Clear
Date

Month Day Year
Date
Navigator Signature

Clear
Date

Month Day Year
Date
Entrance fee is $20 per car payable at the event.

The starting location is at Portage Community Chapel *6490 St. Rt. 14* Ravenna, Oh 44266
Prizes have been donated by local merchants and business owners and are not transferable or redeemable for cash.

The Haven of Portage County does not sell or trade personal information. Privacy Policies are in effect to ensure security and confidentiality at all times including any personal information which the club may keep on file for future
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