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    Registration 2011

    Uploaded by

    jhoenig
    This document is a membership and registration form for Lee County Speedway. It lists various membership and class options including track membership for $25 and reserved parking for $50. It requests driver information like name, address, social security number and class. It also includes a prize money authorization section and liability waiver agreeing to abide by track rules. The driver must complete, sign and pay all fees before receiving prize money.

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    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd

    Registration 2011

    Uploaded by

    jhoenig
    19 views1 page
    This document is a membership and registration form for Lee County Speedway. It lists various membership and class options including track membership for $25 and reserved parking for $50. It requests driver information like name, address, social security number and class. It also includes a prize money authorization section and liability waiver agreeing to abide by track rules. The driver must complete, sign and pay all fees before receiving prize money.

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    © Attribution Non-Commercial (BY-NC)

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    This document is a membership and registration form for Lee County Speedway. It lists various membership and class options including track membership for $25 and reserved parking for $50. It requests driver information like name, address, social security number and class. It also includes a prize money authorization section and liability waiver agreeing to abide by track rules. The driver must complete, sign and pay all fees before receiving prize money.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    19 views1 page

    Registration 2011

    Uploaded by

    jhoenig
    This document is a membership and registration form for Lee County Speedway. It lists various membership and class options including track membership for $25 and reserved parking for $50. It requests driver information like name, address, social security number and class. It also includes a prize money authorization section and liability waiver agreeing to abide by track rules. The driver must complete, sign and pay all fees before receiving prize money.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    of 1

    For Office Use

    Office Use Only

    Track Membership $25


    Car # ________
    IMCA Modified, IMCA Stock Car, Hobby Stock
    IMCA Sport Modified, 4 cyl. Wild Thing Class ________
    Reserved Parking Available - $50
    PO Box 226, Denmark, IA 52624
    (319) 528-4301 * Fax (319) 528- www.leecountyspeedway.com Pkg # ________
    4302
    OFFICE USE ONLY

    Rcd. By _________ Date Paid _________ Amount _________ Cash CC Check # ______ IMCA 
    This form MUST be completed, signed and all fees paid in order to receive prize money. PLEASE PRINT CLEARLY!

    DRIVER’S Name ________________________________________________ Car# _________________

    DRIVER’S Social Security # ______________________________________ Class _________________

    DRIVER’S Address _____________________________________________________________________

    City _______________________________________ State _________________ Zip Code ______________

    Phone # ____________________________ e-mail address ______________________________________

    Cell Phone # _________________________  Check this box to receive Text Message Updates (such as Rain outs)

    PRIZE MONEY AUTHORIZATION – If other than driver


    Person or Business that Federal 1099 should go to if other than above – If same as driver you may leave blank.
    Required by Federal Government to avoid a 28% withholding of prize money.

    SS# or Federal ID # _________________________________________________ (must match check’s payable)

    Make Checks Payable to ____________________________________________________________

    Address _______________________________________________________________________________

    City ____________________________________ State _________________ Zip Code _________________

    Phone # ____________________________ e-mail address ______________________________________

    Cell Phone # _________________________  Check this box to receive Text Message Updates (such as Rain outs)

    AGREEMENT
    CONTRACT: I am an independent contractor assuming all responsibility for money received as a result of my activities
    including, without eliminating, income tax, FICA, workman’s compensation and withholding taxes. I am not an employee,
    servant or agent of Lee County Speedway, Inc.
    BENEFITS: I agree that myself, executors, and assigns will be entitled only to the benefits of the Competitor Accident
    Policy procured by Lee County Speedway, Inc. for accidental injuries which are the result of external, violent, and visible
    means sustained in Lee County Speedway, Inc. events. The foregoing shall constitute the limit of liability of Lee County
    Speedway, Inc. for such injuries occurring to me in any Lee County Speedway, Inc. event provided proper notification is
    given.
    COMPLIANCE: The undersigned agrees to abide by all rules and regulations of Lee County Speedway, Inc. now published
    or hereinafter modified. In consideration of the acceptance by Lee County Speedway, Inc. of this agreement the
    undersigned recognizes his obligation to the public and Lee County Speedway, Inc. which posts the prize money and
    conducts the events, and agrees to compete in all events when qualified if humanly possible.
    BREACH AND DAMAGE: In the event the undersigned breaches this agreement he shall be liable for actual liquidated
    damages sustained by Lee County Speedway, Inc.
    OWNERSHIP: If owner of a registered car, I certify I have good and marketable title to said vehicle or any part thereof in
    the event the same is claimed pursuant the rules.
    ADVERTISING RELEASE: The undersigned consents to the use of his name, pictures of himself, and his car for publicity,
    and relinquishes any rights to photos taken in connection with events and consents to the publication or sale of such
    photos as Lee County Speedway, Inc. so desires.
    ARBITRATION: Any controversy or claim arising out of or relating to this agreement including any alleged breach, shall be
    settled in accordance with the rules and regulations of the Lee County Speedway, Inc. and the undersigned agrees to
    accept the decision rendered by this process.
    I HAVE READ AND FULLY UNDERSTAND THIS AGREEMENT. I AGREE TO ABIDE BY ALL TERMS OF
    THIS AGREEMENT AND THE REQUIREMENTS OF THE RULES OF THE LEE COUNTY SPEEDWAY, INC.

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