Orleans Raceway LLC

Cash Back 350 - Pre-Registration - Date: ______________________________

Class: ____________     Car #:_______     Make: ________     Color: ___________

Car Sponsors: _______________________________________________________

__________________________________________________________________

Driver's Name: ________________     Car Owner's Name: ____________________

Driver's Address: _______________    Car Owner's Address: __________________

____________________________     ____________________________________

Driver's Phone #:_________________ Car Owner's Phone #:___________________

Emergency Contact Name & #s: _________________________________________

Driver's SS#:________________     Car Owner's SS#:________________________

PayOut goes to:       Driver      or     Car Owner    (circle one)

Cash Back 350:

Registration Fee: 2 day pit pass for driver mandatory $75.00 per car per class (Late Models $80)

Sprints, Late Models, UMP, IMCA, MMA Modified, Hobby/Street Stock, Pro Stock/Truck, 4 CYL FWD & 4 CYL RWD

DECLARATION

            I have read the regulations issued for this event by the Orleans Raceway LLC and agree to be bound by them.  I am fully aware that participating in a race is a potentially hazardous activity and I assume any and all risks associated with participating in this event.

            In consideration of the acceptance of this entry or of me being permitted to take part in the above-named event, I agree to save harmless and keep indemnified the Orleans Raceway LLC, its owners and/or stockholders, such persons who promote or organize events and their respective officials, servants, representatives and agents from and against all actions, claims and costs, expenses and demands in respect of death or injury to myself whatsoever the cause, arising out of or in connection with this entry, or my participating in the event, and notwithstanding that the same may have contributed to or occasioned by the negligence of the said bodies, their officials, servants, representatives or agents.

            Furthermore, in respect of any part of this event on ground where third party insurance is not required by law this agreement shall in addition to the parties above named extend to all and any other competitor/s and their servants and agents and to all actions, claims, costs, expenses and demands in respect of loss or damage to the person or property of myself, my driver(s), passenger(s) mechanic(s) or associated personnel.

            Furthermore, I declare that to the best of my belief that I, the driver, possess the standard of competence necessary for an event of this type to which this entry relates and the vehicle I have entered is suitable and roadworthy for the event with regard to the course and the speed which will be reached.

            Furthermore, I understand that should I at the time of this entry be suffering from any disability or medical condition whether permanent, temporary or otherwise, or if I am under the influence of a controlled substance prescribed or not, which is likely to affect prejudicially my normal control of my vehicle, that I may not take part.

            I further grant full permission to the Orleans Raceway LLC and/or agents authorized by them, to use any photographs, videotapes, motion pictures, recording, or any other record of this event for any purpose.

  Date: _____________    Driver’s Signature: ________________________________

                                         Print Driver’s Name: ______________________________

                                         Witness Signature: ________________________________

                                         Print Witness Signature: ___________________________

If driver is under 18 years of age Parent must sign thereby granting permission to race & agreeing to the terms as set forth above.                                              

 _______________________________

Parent’s Signature

 _______________________________

Print Parent’s Name