Registration Form
Please fill out the form below to Pre register for Pixler Chiropractic's Wish For Hero Car and Bike Show.
First Name
Last Name
Phone
Email
Street
City
State
Zip
Vehicle Type
Make
Model
Year
Pre-entry fee (by June 25th) $11
Send check or money order to: Dr John Pixler, 903 College Mall Rd Bloomington, IN 47401 or here via Paypal www.paypal.com/cgi-bin/webscr?cmd=_s-xclick&hosted_button_id=AJNN7MGJ9UKKS
Select Your Shirt Size Below
Those who pre-register (By June 25th) will qualify for a FREE car show t-shirt
By signing below, I agree to release Dr John Pixler Chiropractic , their sponsors, vendors, members, officers, and anyone else affiliated of any known or unknown damages, injuries, losses, judgments, and/or claims from any cause whatsoever. No outside alcohol is permitted. Any lewd or obnoxious behavior is prohibited and will result in having to leave the event/premises. Once registered NO refunds will be granted (unless event is cancelled by event coordinators). It is also agreed, by signing below, that the vehicle you have registered carries at least the state minimum insurance, and that it is the sole responsibility of the owner of the above registered vehicle for any damages made to any property and/or persons that is caused by registered owner.
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy