2012 DRIVER REGISTRATION FORM

Cost per Driver: $25/season or $10/night

Driver _______________________________________Class________________            Car #_____________

Address ______________________________ City____________________ State _______ Zip ________ 

Cell Phone_________________________   Home Phone ___________________________

Email Address ___________________________ SSN or Fed ID__________________________

Birth Date ________________ Jacket Size ______________

MODIFIED DRIVERS: USRA MEMBER      YES      NO     Membership # ___________

TAX AUTHORIZATION

If owner is to receive 1099 please fill out the following information: 

Owner _____________________________________________SSN or FedID______________________

Address __________________________ City_______________________ State _______ Zip ________ 

Cell Phone_________________________   Home Phone ___________________________

Owner Signature: _____________________________________________________________

Emergency Contact Name:_______________________Phone:_______________Relationship________

Is there any medical reason you should not be racing:_______Do you have health insurance:________

Driver Signature:_______________________________________Date:___________________________

Email form in advance to: mid.americaspeedway@yahoo.com or bring to track first night.

Questions on registration or if you need USRA Registration: Call Jennifer @ 918-766-6960.