Driving the Dixie

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Name *

Address *

City *

State *

Zip *

Phone

How did you hear about the event? *

Make and Model *

Year of the Vehicle *

Insurance *

Insurance carrier *

Policy # *

I certify that on June 19th, 2010 my drivers license, vehicle registration and automobile liability insurance are current and valid. I agree neither that A's R Us chapter, Model A Ford Club of America nor the Dixie Highway communities are responsible for loss or injury to property or myself. I shall assume any, and all liability for such loss, damage or injury. Further, any loss or damage caused by myself to others shall be my personal responsibility. Additionally, In understand that all traffic control devices, speed limits, or other traffic regulations will be obeyed during my participation in the event.

Online signature *

Re-typing or signing verifies understanding of waiver

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Send this form along with $10.00 for Pre-Registration payable to:A’s R Us, P.O. Box 3, Crete, IL. 60417 Pre-registration ends June 12, 2010 ~~~~~~~~~~~~~~~~~~ Day of Event Registration is $15.00

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Header picture:

1931 Ford AA truck. Typical signage of the period on the truck. This picture was taken at Crown Point during the filming of "Public Enemies" in 2008.