Home

Kidder Rd.  P.O. Box 273 Bradford, Vt. 05033

(T) 802/222-4052 (H) 603/787-6352 Fax 603/787-2490
www.bearridgespeedway.com

USE THIS APPLICATION FOR MEMBERS DO NOT USE TO REGISTER A RACE CAR & IT’S OWNER and/or DRIVER. If you need more membership applications, feel free to photocopy this form.

        MEMBERSHIP FEE - $50.00                                                                    Mail completed forms to:

        AFTER March 1^ST  $75.00                                                                Bear Ridge Speedway

PO Box 273 Bradford VT 05033   

 

THIS FORM MUST BE FILLED OUT IN FULL CAR NUMBER AND DIVISION MUST BE COMPLETED!!

 FULL NAME                                                                                                                                                            

ADDRESS                                                                                                                                                               

CITY                                                                                       STATE                       ZIP CODE                            

PHONE                                                                      EMAIL ADDRESS                                                             

Date of Birth                                                  Place of Birth____                                                                          

Employed by:                                                                                                phone                                                           

Address                                                                     City                             State               Zip Code                   

Emergency contact                                     Relation                                 Phone                                                           

Do you have any handicaps or disabilities?  Yes   No   If yes, describe on back of this form & sign.

Date of last physical exam                                     Physical Condition                                                             

Do you currently have health insurance? Yes   No   If yes, fill out information below

Name of Insurance Company/Plan                                                         Agent                                                

Agent’s Phone                                             Address                                                                                            

ADVERTISING RELEASE: The undersigned consents to the use of his/her name and/or pictures of him/herself and his/her car, for publicity, advertising and endorsement both before and after events and relinquishes any rights to photos taken in connection with events, and consents to the publication or sales of such photos by BRS.

SAFETY RELEASE: I hereby give up all my rights to sue or make any claim against the BEAR RIDGE SPEEDWAY and their organizers, promoters, sponsors and all other persons or organizations conducting or connected with this event for any injury to property or person I may suffer, including crippling injury or death, whether such injury arises while I am preparing for or participating in the event or while I am upon the event premises.

                I know the risks of danger to myself and my property while participating in the event, and while upon the event premises and relying upon my own judgment and ability, assume all such risks of loss and hereby agree to reimburse all cost to those persons or organizations connected with this event for damages incurred as a result of any injury that I cause or receive.

ARBITRATION: Any dispute, controversy or claim involving the undersigned member, whether or not relating to this agreement or alleged breach of same, shall be settled in accordance with the existing and/or amended rules and regulations of the Speedway and the undersigned agrees to accept the decision rendered in the process. I understand there will be no refund of membership fees once paid for any reason.

Date                                                    Legal Signature                                                                                          

Fee must be paid at time of application. BRS reserves the right to reject this or any other application

If applicant is under 18 years of age, a MINOR/PARENT RELEASE must be signed and filed with this application.