Event Registration Be Part of Our Nonprofit Organization’s Future Events ENTRY AND RELEASE FORM SPECIAL AWARDS • Explore Lompoc 'BEST IN SHOW' • CHIEF'S CHOICE • MAYOR'S CHOICE • PEOPLE'S CHOICEName* First Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country PhoneEmail* Vehicle InformationYear*Please enter a number from 1900 to 2020.Make* Model*Class #Class 1 Street Rods 1927–1949Class 2 Specialty VehiclesClass 3 Corvettes 1953–1996Class 4 Corvettes 1997 and NewerClass 5 Muscle CarsClass 6 Chevrolets 55–57Class 7 KustomsClass 8 Asian ImportsClass 9 Euro ImportsClass 10 Camaro 1967–1969Class 11 Camaro 1970 and NewerClass 12 Public SafetyClass 13 AntiquesClass 14 Ford/MercuryClass 15 Mustang 1964–1973Class 16 Mustang 1974 and NewerClass 17 Mopar 2000 and NewerClass 18 Mopar 99 and OlderClass 19 Motorcycles/AmericanClass 20 Motorcycles/Asian and EuropeanClass 21 StudebakersClass 22 TrucksClass 23 Ranchero and El CaminoClass 24 BombsClass 25 WoodiesClass 26 BowtiesClass 27 LowridersClass 28 Lowrider TrucksClass 29 Rat RodsClass 30 Bicycle (No Fee)Class 31 VOLKSWAGENClass 32 General Motors carsClass 33 "Klunkers"Class 34 Club Participation (no fee)Class 00 Period Costume (no fee)Club AffiliationClub Affiliation In consideration of the acceptance of the right to participate, the undersigned hereby voluntarily releases, discharges, waives, and relinquishes any and all actions or courses of action for personal injury, property damage, or wrongful death occurring to himself arising as a result of engaging in, or receiving instructions in, said activity or any activities incidental thereto wherever or however the same may occur and for whatever periods that activities or instruction may continue, and the undersigned does for himself, his heirs, executors, administrators, and assigns hereby release, waive, discharge, and relinquish any action or course of action, aforesaid, which may hereafter arise for himself and for his estate, and agrees that under no circumstances will he or his heirs, executors, administration, administrators, and assigns prosecute, present any claim for personal injury, property damage, or wrongful death against the City of Lompoc or any of its officers, agents, servants, or employees for any of said causes of action, whether the same shall arise by the negligence of said persons or otherwise. I/we are the parent(s)/guardian(s) of a minor. We hereby consent to the said minor's participation in the above described City of Lompoc activity. We hereby agree to indemnify and hold harmless the City of Lompoc from any claim for injuries or damages that said minor may have against the city by reason of his participation in said activity.Entrant's E-Signature Date* MM slash DD slash YYYY Signature of Parent/Guardian Date MM slash DD slash YYYY Number Δ