Name:________________________________________

Club Affiliation:________________________________________

Address:_______________________________________________

City:_____________________ State:________ Zip:_________

Phone:____________________________________

Email:______________________________________________

Make :___________________________________________

Model:____________________________________________

Year:______________________________________________

Color:______________________________________________

Special Attributes:______________________________________

____________________________________________________

____________________________________________________

Signature:______________________________

Date:_________________________________

Make Checks Payable to :

East Jordan Lions Club

Send Form with payment to :

East Jordan Lions Club

PO Box 845

East Jordan, MI, 49727

The South arm classics that I will be entering is promoted by the East Jordan

Lions Club and will take place on July 10th 2021. This form indicates that I am the Owner

of the Car/Truck stated above. My signature signifies that I certify that I currently have updated

Insurance to cover any damage to other participants. I hold harmless volunteers and officers

of the south arm classics, the city of East Jordan as well as sponsors and or advertisers from

any actions, claims, assertion of liability that may arise with south arm classics.