Participant Registration Form Arizona Equipment Safety Partnering Roadeo Registration Form Online registration for the Roadeo must be submitted by March 15th, 2013. STATEMENT OF LIABILITY I understand that the Equipment Roadeo involves the movement and operation of large and powerful items of equipment. I also understand that there are risks associated with participating in, observing and attending the Roadeo. I hereby release and hold harmless the State of Arizona, its employees, officers, agents and contractors from all claims, liability and rights of actions for any personal injury and property damage, regardless of the cause, arising from my attendance or participation of the Roadeo. I understand that this release of liability shall apply to any claims that may accrue to myself, my heirs, my estate, my personal representative, and anyone else claiming on my behalf of myself, my estate or my heirs. I agree to these terms and conditions INDEMNIFICATION Public Entities: Each party (as "Indemnitor") agrees to indemnify, defend, and hold harmless the other party (as "Indemnitee") from and against any and all claims, losses, liability, costs, or expenses (including reasonable attorney's fees) (hereinafter collectively referred to as "Claims") arising out of bodily injury of any person (including death) or property damage, but only to the extent that such Claims are caused by the act, omission, negligence, misconduct, or other fault of the Indemnitor, its officers, officials, agents, employees, or volunteers. Private and Non-Profit: All individual Partipants not associated with a public entity must sign this waiver at the event to participate in the events. PAYMENT INFORMATION ADOT Employees must provide a PO number to complete the registration process. Payment Method: Select One Cash Check Purchase Order PO or Check Number: Be sure to print a copy of your registration form and attach a check or money order made payable to Organized Affair (Equipment Roadeo) and submit to Organized Affair, Attn: Michelle Fulcher, 28248 N. Tatum Blvd. Suite B1 #413, Cave Creek, AZ 85331. If you have questions contact Donna LaGuardia at 602.712.6645. ATTENDEE INFORMATION First Name: Middle Initial: Last Name: ADOT Only: Employee ID Number: Org#: Agency/Company/Municipality: ADOT Apache Cnty ASU BIA San Carlos City of Chandler City of Flagstaff City of Tucson Coconino Cnty Gila Cnty MCDOT Navajo Cnty NMDOT NAU Pima Cnty Pinal Cnty R.E. Monk Santa Cruz Cnty Town of Fountain Hills Other if other: Work Address: City: State: Zip: Phone: Fax: Email: Meals Attending: Select One Lunches Only Awards Dinner Only All Meals No Meals Awards Dinner Entree: Select One Chicken Steak Registration Fees: Select One $100.00 Roadeo Attendee $75.00 ASU/NAU Students $30.00 Awards Dinner $50.00 Walk-In Observers (all meals) $20.00 Walk-In Observers (no meals) Are you competing? Yes No INDIVIDUAL EVENTS Each competitor may compete in up to 3 Competitive Events, up to 5 if he/she elects to compete in the Forklift & Van Certification events. The Forklift and Van Certifications count as part of the 3 hours mandatory safety training. Backhoe Dump Truck Forklift Loader Motor Grader Pickup Truck Skid Loader Snowplow Van Certification TEAM EVENTS Craftco Crack Sealing Team Name: Team Member 1: Team Member 2: Team Member 3: Team Member 4: Traffic Control Team Name: Team Member 1: Team Member 2: Team Member 3: Director's Challenge Team Name: Team Member 1: Team Member 2: T-SHIRT INFORMATION Walk-ins and Guests will not receive an event T-shirt. Men's Women's None Size: Select One Small Medium Large XL 2XL 3XL 4XL 5XL Designation: Select One Competitor Non-competitor Judge Score Keeper ASU/NAU Student Training Transport Driver Volunteer Walk-In Select a maximum of two (2) events you will be judging: Backhoe Dump Truck Forklift Loader Motor Grader Pickup Truck Skid Loader Snowplow Van Certification Crafco Crack Sealing Traffic Control LODGING INFORMATION ~ ADOT ONLY Please indicate where you will be staying to assist us in tracking lodging. Select One Lives Locally Best Western - Metro Best Western Inn Suites Candlewood Suites Phoenix Country Inn & Suites Deer Valley Crown Plaza Phoenix Days Inn Doubletree Guest Suites Embassy Suites - Phoenix Airport Embassy Suites - Phoenix North Grace Inn - Ahwatukee Hampton Inn - Phoenix Midtown Hilton Garden Inn Holiday Inn Phoenix North Hotel Highland La Quinta #704 La Quinta North Phoenix Towne Place Suites - Metro Residence Inn Springhill Suites Other Number of Nights: 1 2 3 4 GUEST INFORMATION Be sure to print a copy of your registration form and attach a check or money order made payable to Organized Affair (Equipment Roadeo) and submit to Organized Affair, Attn: Michelle Fulcher, 28248 N. Tatum Blvd. Suite B1 #413, Cave Creek, AZ 85331. If you have questions contact Donna LaGuardia at 602.712.6645. GUEST 1 GUEST 2 Name: Name: Registration Fee: Select One Under 12 Free Lunches Only $30 Awards Dinner Only $30 All Meals $50 Registration Fee: Select One Under 12 Free Lunches Only $30 Awards Dinner Only $30 All Meals $50 Awards Dinner Entree Choice: Select One Chicken Steak Awards Dinner Entree Choice: Select One Chicken Steak GUEST 3 GUEST 4 Name: Name: Registration Fee: Select One Under 12 Free Lunches Only $30 Awards Dinner Only $30 All Meals $50 Registration Fee: Select One Under 12 Free Lunches Only $30 Awards Dinner Only $30 All Meals $50 Awards Dinner Entree Choice: Select One Chicken Steak Awards Dinner Entree Choice: Select One Chicken Steak Total Guest Registration Due: $ Total Due: $0.00 Be sure to print the form prior to submitting.
Online registration for the Roadeo must be submitted by March 15th, 2013.
I understand that the Equipment Roadeo involves the movement and operation of large and powerful items of equipment. I also understand that there are risks associated with participating in, observing and attending the Roadeo.
I hereby release and hold harmless the State of Arizona, its employees, officers, agents and contractors from all claims, liability and rights of actions for any personal injury and property damage, regardless of the cause, arising from my attendance or participation of the Roadeo. I understand that this release of liability shall apply to any claims that may accrue to myself, my heirs, my estate, my personal representative, and anyone else claiming on my behalf of myself, my estate or my heirs.
Public Entities: Each party (as "Indemnitor") agrees to indemnify, defend, and hold harmless the other party (as "Indemnitee") from and against any and all claims, losses, liability, costs, or expenses (including reasonable attorney's fees) (hereinafter collectively referred to as "Claims") arising out of bodily injury of any person (including death) or property damage, but only to the extent that such Claims are caused by the act, omission, negligence, misconduct, or other fault of the Indemnitor, its officers, officials, agents, employees, or volunteers.
Private and Non-Profit: All individual Partipants not associated with a public entity must sign this waiver at the event to participate in the events.
Be sure to print a copy of your registration form and attach a check or money order made payable to Organized Affair (Equipment Roadeo) and submit to Organized Affair, Attn: Michelle Fulcher, 28248 N. Tatum Blvd. Suite B1 #413, Cave Creek, AZ 85331. If you have questions contact Donna LaGuardia at 602.712.6645.
