Your Name:  Spouse's Name:

Anniversary:   Your Birthday:   Spouse's Birthday:

Address:

City:       State:     Zip:

Phone:     Email:

Your PT Cruiser - Year:    Color:      Turbo: Yes No

List any changes you have made to your PT Cruiser:

I realize that activities for this club may involve some potential hazards. I agree that West KY PT Cruisers and its coordinators shall not be held liable by me, my relatives, my heirs, legal guardian or representatives for any act that may result in my injury or death while freely participating in any activities sponsored or organized by the aforementioned organization.

Signature:____________________________________     Date:______________________

 JUST COPY AND PASTE IN AN EMAIL TO gary@westkyptcruisers.com

Or mail to:
The Western Kentucky PT Cruisers c/o Gary Meyer
2003 Dusty Trail
Gilbertsville, KY 42044