Driver’s Registration
Season _____________
Please Print – Fill
Out Completely – Bring to Pit Booth with $50 Registration Fee
Class: ______________
Car#: ___________Colors:____________________________
Car Year:
________________ Make:___________________
Model:______________
Driver Name:
______________________________ DOB: _______________________
SS#_____________________________
DL#/State ______________________________
Address:
_______________________________________________________________
City:
Spouse Name:
_________________________ Kids: ___________________________
Car Owner:
________________________________ DOB: ______________________
SS#_____________________________
DL#/State ______________________________
Address:
_______________________________________________________________
City:
Payout Goes to:__________________________________________________________
Emergency Contact,
Name & Phone: _______________________________________
This portion to be completed by track representative
Name:
___________________________ Car Class: ______________ Car #:________
Date:
______________________ Registration Fee Paid: ________________________
Track Representative
Signature:____________________________________________
(This is your
registration receipt – upon request you may be required to present it for points information and payout.)
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: ________________________________
If under 18 years of Age, Print Driver’s Name: ______________________________
Parent must sign thereby
granting permission to Witness Signature: ________________________________
race & agreeing to the
terms as set forth above. Print Witness Signature: ___________________________
_______________________________
Parent’s Signature
_______________________________
Print Parent’s Name