Visionary Promo Tour

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Email Address:*
Phone Number:*
Can we contact you with a text message?
Drivers Name:*
First Last
Passangers Name
First Last
Tours Attended:*
- First Timer
- One
- Two
- Three or More

Street Address:*
Street Address City State / Province / Region ZIP / Postal Code

RELEASE OF LIABILITY:*
- Yes
Your vehicle must be fully insured and licensed. It is also understood, by your participation in this tour event, that you are accepting full responsibility for any damage, loss, and/or injury of any kind or nature that may result from operation of your vehicle. Further, by your signature and your participation you agree to hold Back to the Bricks® , Inc. and its committee, promoters and sponsoring organizations harmless from any liability which may arise from your participation in this tour. This form will remain confidential with the Back to the Bricks® committee.
Name of Insurance Company:

Comments:

(enter additional passengers, t-shirts or any other information here)
Product Name
Price: $45.00
The cost of the Tour is $45.00. ($60.00 after April 1st) If you want to order extra T-Shirts or Lanyards please list it in the comments below and someone will contact you.
Total
$0.00
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