Driver 1: __________________________________
Driver 2: __________________________________
Street Address: ______________________________________
City: __________________________ State: _______ ZIP: __________
Home Phone: _____________ Work Phone: _____________ Mobile Phone: _____________
E-mail address: ________________
Your Miata:
Year: ______ Color: ________ Package: _____ License Plate: ________
Modifications:________________________________________________________
Release Statement:
I hereby agree to enter the above described vehicle in the activities of the Mardi Gras Miata Club and to participate in other planned events scheduled by the Club. In consideration of the right and privilege to enter and participate in these events and other valuable consideration and intending to be legally bound, I agree to release the Mardi Gras Miata Club, its officers, organizers, members, sponsors and vendors from any and all liability for injury, damages or loss arising from my participation and attendance in any Club activity. Membership is contingent upon compliance with all State Motor Vehicle insurance laws.
Signed: ____________________________ Date: ___________
Signed: ____________________________ Date: ___________
(If spouse or significant other is applying,
they must also sign.)
Please enclose your check
for $25, payable to Peggy McDermott and send this application to:
Mardi Gras Miata Club
12642 Mustang Ave.
Baton Rouge, LA 70818-5833