Porter’s Battery

Application

Name:

Date of Birth:

Street/Mailing Address:

Home Phone:

Cell Phone:

Email Address:

Occupation:

Family:

Emergency Contact Information:

Known health issues:

          I, __________________________________, do hereby and hereafter release Porter’s Battery from all liability in the unfortunate event that I’m injured or other incapacitated while participating in any of their events.

Signed: ______________________________________________