COMBINE DEMOLITION DERBY ENTRY FORM

Year:_______________________ Make:__________________________ Model:_______________________

Combines NOT checked in TWO hours prior to demo time WILL NOT be allowed to run.

Name___________________________________

Address__________________________________ City_________________ State_________ Zip__________

Combine Number _________________________

Sponsors_______________________________________________________________________________

______________________________________________________________________________________

I undersigned do hereby release combine demolition derby promotions, it's employees, agents and any other person,

and/or organizations, involved with the sponsoring and/or the conducting of the combine demolition derby

at ___________________ and on the date of _____________________.  Of any liability arising from the result of

my participation, no expressed or implied warranty of safety shall result from publication of/or compliance with these

rules and regulations.  They are intended as a guideline for the conduct of the event and are in no way a guarantee against

injury or death to participants, spectators, and others.

Driver's Signature: _____________________________________________

License Number _______________________________ State ________________

(Participants under the age of 21, please provide a parent or guardian signature.)

Parent or Guardian Signature: __________________________________________

NOTE: All safety precautions will be taken that are possible as we do not want anyone injured.  We hope all drivers

appreciate this and understand that the judges will have the final say about everything in the area, pit area and track.

Keith County Ag Society, Inc.

Please return to: James Tuma, 741 Road East F South, Ogallala, Ne  69153 (308)289-1142