ESCW Registration Form

Fill in the blanks and print. Bring with you to Eureka Springs.	MEMBERSHIP REGISTRATION
Name:
Mailing Address:
City, State, Zip;
New Mailing Address?
Telephone: (including area code)
Club Affiliation:
I verify that the vehicle entered into the Eureka Springs Corvette Weekend at Eureka Springs, AR is insured against loss, damage and liability. I agree to assume any risks of any and all damages or injury and to indemnify and hold harmless the Eureka Springs Corvette Weekend, Inc. its officers, directors, and agents for any and all acts of omission which may result in the theft, damage, or destruction of my property, or injury to me or others occurring during, or as a consequence of my participation in this Event. *SPECIAL NOTICE*: The Annual Meeting of the Eureka Springs Corvette Weekend, Inc. is held in January in Eureka Springs, AR. For further information, please call 417-862-7232 for exact date.
	Membership/Registration includes all scheduled events ($40)
	Do you want to put your car in the Owner’s Choice Car Show? Limited spaces.

Signature:	______________________________________
Date:	__________________
Color and year of Corvette
State and License Tag Number: