1 REGISTRATION FORM Please submit this Registration form with fees, along with the Application for Entry, Participation Agreement, Havasu 600 Certificate of Insurance, and Contestant Data. Entry Fee must be submitted with the application. Mail completed application forms along with the Entry Fee to Rio Colorado 99s c/o Pam Rudolph 1649 Linda Drive Lake Havasu, AZ 86403 We accept checks made out to Rio Colorado 99s. Credit cards may be accepted, call Pam Names of Crew (Pilot/Co-Pilot) Pilot s Name Cost $265 for crew (includes crew banquet) Email address Phone number Co-Pilot s Name Email address Phone number Passengers name Additional Passengers $ 65.00(includes banquet) Email address Phone number Passenger name $ 65.00(includes banquet) Email address Phone number Awards Banquet Tickets at the Finish in Lake Havasu $ 40.00(for additional guests) Total due (crew+passengers+guests) Total Due If you have guests who would like to join us for the Awards banquet on Saturday evening, additional Banquet tickets may be purchased when you register for $40.00 per person. Please list the names of your guests: Any questions on registration, contact Pam Rudolph hm: 928-855-7594 cell: 928-706-8372 or email me at rudolph@citlink.net (revised 8-17-18)
2 Application for Entry Havasu 600 Air Race This application must be filled out completely and submitted with the Entry Fee. Entry Fee for crew is $265.00 includes pilot & co-pilot, and $65 for each additional passenger. Entry fee must be submitted with Application for Entry. Mail completed Application along with Entry Fee (please make check payable to Rio Colorado 99s) and mail to Rio Colorado 99s c/o Pam Rudolph 1649 Linda Dr. Lake Havasu AZ 86403. 1. Pilot Name: Address: t-shirt size Phone # s: FAA certificate No. and grade total hrs Total hours Date of Medical or BasicMed 2. Co-Pilot Name: Address: t-shirt size Phone # s: FAA certificate No. and grade total hrs Date of Medical or BasicMed 3. Passengers Name: Address: Phone t-shirt size Name: Address: Phone: t-shirt size
3 4. Airplane Make: Model Year Color Registration No. N Serial No. Engine Make Model HP Fuel No.of main tanks Total gallons total usable fuel Is aircraft equipped with auxiliary fuel tanks/tip tanks/extended range tanks? no. of gallons 5.Airplane Owner Name: Address: Phone # s 5. Hold Harmless In making this application for entry in the Havasu 600 Air Race, I hereby release the Rio Colorado 99s chapter, the Ninety-Nines, the cities of the Start, Overnight, and Terminus, and all other cities involved, and all others connected with the race and agree to save said persons harmless from any claim against them or either of them arising directly or indirectly through my participation of any person in my aircraft in the race. 6. Compliance with Specifications I hereby certify that the airplane which I shall use in this race meets the specifications as stated in the Official Rules and Regulations. 7. Agreement to submit for inspection: I hereby agree to submit my airplane and/or enging for extensive inspection at the Start and at the Terminus of race as provided in Rules and Regulations. 8. Agreement to Comply: I hereby agree to be bound by the Rules and Regulations which I have read and which are incorporated as terms and conditions of my participation in this race. I further agree to be bound by any and all changes in or additions to the Rules or Regulations or modifications thereof promulgated by the proper race authorities and communicated to me prior to the Start of the race. I understand that my plane is not to be released from Impound until after the results are announced. I further understand that I may be eliminated from the race at any time before, during, or after the race, for any reason deemed sufficient by the Race Committee. Pilots Signature date Co Pilot s Signature date Passenger Signature date Passenger Signature date
4 Participation Agreement Havasu 600 Air Race 1. I hereby certify that I am participating in the Havasu 600 Air Race with the highest interests in aviation safety and good sportsmanship. I understand and agree that the Havasu 600 Air Race is presented as a fun race, and is conducted as a means to improve and test the safe flying skills of all contestants. I further agree, in the interests of aviation safety and good sportsmanship that since this is presented as a fun race for contestants, officials, and other participants, to do all in my power to ensure that all parties connected with the race have a good time. 2. I hereby agree to abide by the Havasu 600 Air Race Rules and Regulations, which I have read and which are incorporated as terms and conditions of my participation in this race. I further agree to abide by any and all changes in, or additions to, the Rules and Regulations or modifications thereof promulgated by the proper Havasu 600 Air Race officials and communicated to me in writing prior to the start of the race. I understand that I may be eliminated from the Havasu 600 Air race at any time before, during, or after the race for any reason deemed sufficient by the race officials. 3. I hereby certify that the aircraft which I shall use in the Havasu 600 Air Race meets the specifications as stated in the Rules and Regulations, governing the current Havasu 600 Air Race. 4. I hereby agree to submit my aircraft for extensive inspection at the Start and Terminus of the race as provided in the Rules and Regulations, and to allow the inspection committee to check it in flight, straight and level, throttle wide open. Federal Aviation Administration Certificated Mechanics, authorized by the officials of the Havasu 600 Air Race may conduct or perform any examination to establish that the aircraft conforms to the manufacturer s stock model rating and to the standards by which it is certificated. I understand that my aircraft is not to be released from impound until after the terminus inspection has been completed. I have read and understand the terms of the Participation Agreement. Pilot s Signature date Co-Pilot Signature date Passenger Signature date Passenger Signature date
5 HAVASU 600 AIR RACE Certificate of Insurance November 8 November 10 2018 INSTRUCTIONS TO FLYING PARTICIPANTS: Have this form completed by the insurance company which covers the *aircraft you plan to use in the flying event Include this form with your Entry Forms and mail to Rio Colorado 99s c/o Pam Rudolph 1649 Linda Drive Lake Havasu, AZ 86403 Do NOT bring your insurance policy or a copy; it cannot be accepted in lieu of a certificate of insurance A certificate issued on the insurance company s form is acceptable provided it describes or names the event, date(s) of insured s participation and the Limits of Liability, and stated policy has been endorsed as requested below** CERTIFICATE OF INSURANCE This is to certify to the Rio Colorado Chapter of the Ninety-Nines, Inc., whose address is: Rio Colorado Chapter of the Ninety-Nines, Inc., 689 Empress Drive, Lake Havasu, AZ 86404, that Policy No. has been issued for the period from to TO: Aircraft Owner/Insured Name Address Covering in accordance with the terms and conditions thereof, the following aircraft Make Model Registration #N *Helicopters, Homebuilt and Experimental aircraft, and Balloons are not eligible to participate. **ADDITIONAL INSUREDS: This policy has been endorsed to include the Ninety-Nines, Inc and the Rio Colorado 99s Chapter as additional insured s as respect to chapter sponsored flying event(s), for aircraft liability coverage as indicated below. Event Contestants: TYPE OF COVERAGE LIMITS OF LIABILITY-NOT LESS THAN: 1. AIRCRAFT LIABILITY ( ) Combined Limit, $1,000,000.00 each occurrence or accident Including passengers and property damage With no sub-limits OR ( )Single Limit Bodily Injury Including passengers and property damage (passenger sub-limit at least $100,000.00) $1,000.000.00 each occurrence of accident 2. AIRCRAFT PHYSICAL DAMAGE (Hull, Optional) Amount of Insurance: All risks, Not in Motion, In Motion, In Flight $ 3. This insurance is in full force and effect with respect to liability arising out of use of the aircraft in connection with the flying event described as: the Havasu 600 Air Race to be conducted on/or about November 9-12, 2017 4. It is the intention of the Company that in the event of cancellation of the policy by the company, ten (10) days written notice of such cancellation will be given to you at the address stated above Signed by Name of Insurance Company Insurance Underwriter Date
6 AIRPLANE N # MAKE MODEL SERIAL NUMBER ENGINE MAKE MODEL TAKE OFF HP MAX CONTINUOUS HP PROPELLER FIXED PITCH CONSTANT SPEED FUEL NUMBER OF MAIN TANKS EQUIPPED WITH AUX TANKS? TOTAL GALLONS IN MAIN TANKS NO. OF GALLONS REQUIRED AIRCRAFT DOCUMENTS (MUST BE IN AIRPLANE) YES NO VALID AIRWORTHINESS CERTIFICATE? REGISTRATION CERTIFICATE? (OR APPLICATION FOR REGISTRATION OR DEALERS REGISTRATION CARD) APPROVED FLIGHT MANUAL? (OR FAA OPERATING LIMITATIONS/PLACARD) WEIGHT AND BALANCE UP TO DATE? REPAIR AND ALTERATION FORM ACA337 (IF APPLICABLE) AIRCRAFT AND ENGINE LOGBOOKS UP TO DATE DATE OF LAST ANNUAL/OR 100 HR (if applicable) ENTERED PROPERLY? CURRENT COMPASS DEVIATION CARD IN AIRCRAFT? ELT BATTERY EXP DATE WORKING? ADS-B TRANSPONDER INSPECTION DATE SIGNATURE OF PILOT DATE SIGNATURE OF INSPECTOR DATE