Adventure 4WD, Inc. (formerly Let’s Go Jeepin) Registration Form

(check trip type) A4WD I ___ A4WD II ___ Adventure___ Corporate ___ Custom ___

Date of trip: ______________

Name of Participant:

Driver’s license number:                                 State Issued:

Mailing address:

City, State, Zip:

Phone:

Fax:

Email:

Emergency contact name, relationship to you, and phone number:

 

Off-highway Driving experience

Level of experience (circle one):

none    some    limited    moderate    expert

Type of experience, if any (circle all that apply):

mud    rocks    sand    water    hills    off-camber    woods    snow

Where did you acquire your experience, if any?

(ex. Moab, Tellico, Palo Duro, National Forests, etc.)

Who taught you?

(ex. family, friends, 4WD club, organized event i.e. Jeep Jamboree, Challenge etc.)

Vehicle information

Your vehicle is REQUIRED to have the following: working four wheel drive system, seat belts, and

frame mounted (not welded) front and rear tow hooks. Please ask if you do not understand this!

Year:                                                    Make and model:

License plate number:                            State issued:

Insurance company:                               Policy number:

Passengers

Name, age (if under 18), relationship (sister, husband, daughter, friend, etc.)

1.                                                         2.

3.                                                         4.

Payment Information

___ Deluxe Package $425 ___ Basic Package $295 ____Passengers $75 each

(call for pricing on the following) ___ Adventure ___ Corporate ___ Custom

TOTAL AMOUNT DUE ____________

_____ I have enclosed a check or money order payable to "Adventure 4WD, Inc."

_____ I would like to pay by Visa/MasterCard/Amex

    credit card number ______________________________________________________

    expiration date _____________________

***please fill in your BILLING zip code if you are paying by credit card (for your security!) ____________

I certify that the above information is true and correct and will remain valid and in effect through the duration of my participation in the Adventure 4WD, Inc. events listed above. Any false or omitted information is grounds for expulsion from the event without refund. In the event any dispute, contract or tort, the laws of State of Indiana shall apply without exception. Any misrepresentation of fact may be grounds for expulsion without refund.

Signature          ________________________________

Printed Name    ________________________________

Date                  _________________

Please fill out this form and the waiver completely and mail to

Adventure 4WD TRIP REGISTRATION; P.O. Box 476605; Chicago, IL 60647

or FAX with credit card payment to 773-395-8463