2nd Annual
Piatt County Farm Bureau
Foundation Tractor Drive
Saturday, July 22, 2017
Host Location: Plunk Brothers Seed Shed-Mansfield, IL
DRIVER APPLICATION
Registration Deadline: $50 (If registered by July 10th, you will be entered into a drawing for a
$150 FS fuel card)
Lunch, refreshments & giveaways are included in registration
Please remit payment and forms to:
Piatt County Farm Bureau Foundation
427 West Marion Street
Monticello, IL 61856
(217) 762-2128 P
www.piattcountyfarmbureau.com
[email protected]
PERSONAL INFORMATION (Please print clearly)
Driver’s Name:
Date of Birth:
Address:
City:
State:
Home Phone:
Cell Phone:
Zip:
Email Address:
TRACTOR INFORMATION
Tractor Make:
Model:
Year:
Name of insurance provider:
DRIVER SAFETY PLEDGE
I,
, pledge that by signing the Driver Safety Pledge for the 2017 Piatt County Farm Bureau
Foundation Tractor Drive, agree to abide by all the rules set forth and that my tractor and I will meet all necessary requirements. I
pledge to obey the following rules:
 To have a valid driver’s license.
 To have insurance on my tractor.
 To follow all traffic laws understanding that my tractor is considered a motor vehicle while driving on Illinois roads.
 I will have my tractor(s) fully fueled upon arrival.
 To not carry riders.
 To stay with the group (pace of this drive is 10-12 miles per hour).
 To not pull anything with my tractor during the ride.
 To have an SMV (slow-moving vehicle) emblem posted on my tractor.
 To follow the instructions of the group leader and sponsoring organizations.
 To not pass other tractors on the ride unless instructed to do so.
 To not consume any alcohol, prescription medication, or over-the-counter medications that may impair my ability to drive.
 To bring a tow rope and/or chain.
I understand breaking these rules will result in denial of all future applications. Violators will be asked to leave the ride per the
discretion of the Ride Management Team.
Signature:
Date:
CANCELLATION POLICY
The ride will take place, rain or shine. Please be prepared. No refunds will be given. An alternate date will be
set for extreme weather conditions.
Consent and Release of Liability and Assumption of Risk
NOTICE: THIS RELEASE IS A CONTRACT WITH LEGAL CONSEQUENCES. READ CAREFULLY BEFORE SIGNING.
In consideration of your acceptance of this entry and allowing me to participate in the Piatt County Farm Bureau
Foundation Tractor Drive, and being permitted to drive a tractor in the event; I on behalf of my heirs, assigns, and legal
representatives, do hereby release and forever discharge the Piatt County Farm Bureau and the Piatt County Farm Bureau
Foundation, and any and all of their affiliated organizations, parents, subsidiaries, successors, assigns, directors, officers,
agents, managers, members and employees from any and all claims, demands, actions or causes of action, including injury,
death or damage to property, which may occur during or as a result of participation in the event. Further, I attest that I
have full knowledge of the risks involved in this event and am physically able and sufficiently trained to participate. I
assume all risks associated in participation in this event. Further, I hereby consent to the use of my name, photographs,
motion pictures or other reproduction of myself by the Piatt County Farm Bureau or its agents solely on behalf of the Piatt
County Farm Bureau, or successors or assigns of the Piatt County Farm Bureau for any purpose whatsoever, including any
advertising, trade, commercial, or art purpose; and use in any publication or other advertising media, including the
internet, without limitation or reservation.
Participant’s Name:
Date:
Participant’s Signature:
Parent/Legal Guardian Signature (If participant is under age of 18):
Please remit payment and
forms to:
Piatt County Farm Bureau Foundation
427 West Marion Street
Monticello, IL 61856
(217) 762-2128 P
www.piattcountyfarmbureau.com
[email protected]
OFFICE USE ONLY
Payment Method
Check #
Amount Paid
Date Received
Proof of License
Host Location: Plunk Brothers Seed- 2577 N 1200 East Road Mansfield, IL 61854