MINOR’S NOTARIZED FORM

THIS FORM MUST BE FILLED OUT AND NOTARIZED FOR ANY PARTICIPANT UNDER THE AGE OF 18 FOR EACH AND EVERY WNYOA EVENT.

I, _____________________________________________________________________

GIVE AUTHORIZATION TO:

(An authorized adult)

TO ACT ON MY BEHALF OF THE PARENT AND/OR LEGAL GUARDIAN TO BE RESPONSIBLE FOR THE MINOR DURING THE WNYOA HARE SCRAMBLE EVENT TO BE HELD ON:

(Date of Event)

PARENT OR LEGAL GUARDIAN SIGNATURE:

PARTICIPANT’S SIGNATURE:

SUBSCRIBED AND SWORN TO BEFORE ME ON

THIS ____________ DAY OF____________________________ 2008.

MY COMMISSION EXPIRES:

NOTARY PUBLIC SEAL: