In consideration of the acceptance by MVSCC of this application, issuance of license, my being permitted on the speedway or raceway premises or any of the foregoing, I, for myself, my heirs, next of kin, personal representatives and assigns, FOREVER RELEASE, REMISE and FOREVER DISCHARGE and AGREE TO HOLD HARMLESS and INDEMNIFY MVSCC, the promoters, presenting races or other events, the owners and lessees of premises on which MVSCC events are presented, the participants thereon, and officials and MVSCC members , of, and from all liability, claims, actions and of possible causes of action whatsoever including negligence of any of the foregoing that may occur to me or my heirs, next of kin and personal representatives from every and any loss, damage and injury (including death) that may be sustained by my person and property while in, about and enroute into and out of premises of any events presented.
I HEREBY CERTIFY that any license granted hereunder is granted for the sole purpose of enabling me to participate in the furtherance of any enterprise, to wit, a race, or other motor-sports related activity. My presence in, about, or enroute into or out of any premises where events are presented is in furtherance of that event.
BY MY SIGNATURE BELOW, I hereby forever RELEASE and ASSIGN to MSVCC all rights to my image and the image of the vehicle described below, whether portrayed in still or in motion pictures, drawings or other artistic renderings, related to or depicting my participation in MVSCC events.
Today’s Date_______________________ New Membership ____________________ Car Number ________________
Class: Limited Sportsman ____________ Sportsman ___________ Modified ____________ Show ______________
Driver’s Name ___________________________________ Car Owner’s Name __________________________________
Driver/Owner (Full Membership) Plus two associate’s: $45.00 (US Funds Name: __________________________________
Associate 1 name__________________________________ Associate 2 name _________________________________
Driver Address _______________________________________ City_________________________________________
State/Province _________________________ Country: USA _____ Canada _____ Zip/Postal Code_________________
Home Phone# (____)______-__________ Work Phone # (____)________-_________ Other # (_¬___)______-________
Email Address: _____________________________________________ Birthdate _____________________________
Marital Status: Married ____ Single ____ Spouse’s Name: _____________________
Children: Name(s) & Age(s) if applicable: _______________________________________________________________
Driver Facts (applies to driver only)
Favorites – Racetrack: _______________________________________ Hobbies: ______________________________
Color: ___________ Sports: _________________ Singer: ____________________ Occupation: _________________
Employer Name & Location:_________________________________________________________________________
Racing History: Years raced: _______________ Class(es) Raced: _______________________________________
Car Info: Body Year ___________________ Coupe ________ Sedan ________ Coach ________ Other ____________
Type of Chassis _______________________ Engine: Built by__________________________ Chevy_________
Ford_________Other_____________________ Size ____________ Crew _________________________________
Mail with check to: Lori Cole Treasurer, 30 Cole Drive Woodbourne, NY 12788 or Call (845) 985-7271