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(Please type or print. This form must be printed out and mailed to the address listed below along with your entry fee.) Driver's Name: ___________________________________________________ Address: ________________________________________________________ City, State, Zip ___________________________________________________ County _________________________________________________________ Phone: _________________________________________________________ Driver's License No: _______________________________ State: __________ (Please
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The registration fee must be sent along with registration form to: Derby Entrants: if you are interested in purchasing a video please include the $15 fee with your entry form! Please mark Box! No refunds are available for any reason. There will be a $25 charge on all checks that don't clear the bank and the check will be turned over to law enforcement. I have read the rules and accept the decision of the judges as final. I agree to use the track in the present condition. I understand that the sponsors and administrators of the contest are not responsible for liability in any accident, injury, damage or mechanical breakage, should any occur. In consideration of the acceptance of this entry, I hereby for myself, my heirs, executor and administrators, release and forever discharge the sponsors, administrators, their agents, servants and all other persons connected with these competitions of and from any and all rights, claims, demands and actions whatsoever that I may have for any and all loss, damage or injury sustained by me or my equipment during said competitions. Note: There will be no refunds for late scratches.
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