1. Driver Info: Driver's Full Name:____________________________________________________________________

Email Address:__________________________________________ (Needed for Confirmation)     □ I want to be on the Email list

Day Time Phone:(         )______________________________     Cell Phone:(           )______________________________________

Emergency Contact:_________________________________________  Tel:(           )______________________At Track:_________

How do you rate yourself (Check One):

You must have prior race/driving school experience before you can run in the Intermediate and Advanced groups.

______Beginners -No Track Experience and Training or Very Little

______Intermediate  -Some Track Experience and Training

______Advanced  -Lots of Track Experience With Lots of Training, Especially By Reputable Driving Or Racing Schools

Which performance driving school(s) have U participated?: _________________________________________________________

2. Payment Info: (Late Fee Payment At Track if space is available- Add $25 CASH Please.)

(If Different From Above)  Name on Card:_________________________________________________________________________

Address:________________________________________  Apt:______  City:____________________  State:_____  Zip:________

Credit Card Number:_____________________________________________     Expiration:_____________  Amount:$___________

3. Medical Info: (Please fill out to the best of your knowledge, this info will be helpful if there is an emergency.)

Blood Type:________(If Known)     Date of Birth:___________________     Date of Last Tetanus:__________________(If Known)

Drug Allergies or Medical Conditions:______________________________________________________________________________

Current Medications:___________________________________________________________________________________________

Illness/Injury from Past 12 Months:________________________________________________________________________________

Check If Any Applies:           ___Contacts        ___Dentures       ___Asthmatic       ___Diabetic       ___Epileptic

                                        ___Allergies        ___Hemophiliac       ___Organ Donor      ___Heart Problems

  (Optional)  Religious Preference:____________________________________________________________

4. Vehicle Info: (This will help us classify which group to put you)

Make:________________________________________     Model:_________________________________     Year:___________

Engine Displacement:___________ Car Number:________(If Any)    (Check If Any Applies)  ___Turbo  ___Supercharger  ___Race Tires

Modifications:_____________________________________________________________________________________________

Comments:_______________________________________________________________________________________________