2012 Five Mile Point Speedway Membership Application
Please Check One: Driver Membership _____ Crew Membership _____
Applicant Name: ___________________________________________ Car #: _____________
(car numbers will not be assigned until fmp office receives receipt of paid membership application)
Applicant Address: _____________________________________________________________
(please print and fill out completely)
__________________________Zip Code: ______________ S.S #: _______-______-______
Racing Division: Mod ____ SM ___ IMCA ___PS ___Figure 8___Cats: novice___ expert____
Birth Date: ____/____/____ Phone Numbers: (h) __________________ (w) _________________
Cell Phone Number: ___________________ Email Address: __________________________
Driver Website: ______________________ Other Car # Choices: _____________________
Car Owner: ____________________________ S.S #: _______ - _______ - _______
Owner Address: _____________________________________________ Zip Code: __________
Phone Numbers: (h) ____________________ (w) __________________ (c) ___________________
THE PERSON THAT ANY PURSE OR POINT FUND MONIES ARE PAID TO SHOULD BE LISTED
ABOVE AS CAR OWNER WITH COMPLETE INFORMATION PROVIDED.
Every driver wanting to be eligible for point fund awards, contingency or bonus awards must file a membership award. This includes any or all bonus lap money, giveaways or promotional incentives. The Five Mile Point Speedway Membership Card will be sent to each individual and will provide the lowest discounted pit admission price at each event when offered. Anyone entering the pit area is considered a “participant” with a race team but may only receive the posted discounted pit price with a fmp membership card.
Cost $50 prior to March 21, 2012 cost after March 21, 2012 is $60
IN CONSIDERATION of the acceptance of this Five Mile Point Speedway Membership Form, 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 the promoters presenting races or other events, the owners (lessors) of the premises at which these events are held, the participants, theron, and the owners, sponsors and manufacturers of all racing equipment used in any of these events, the officers, directors, agents, employees and servants of all of them, including officials and Five Mile Point Speedway members, Southern Tier Micro Reality Racing, Inc. (STMRR, Inc.), Five Mile Point Speedway, Inc. of and from all liability, claims, action and of possible causes of action whatsoever. Including negligence of any of the foregoing, that may accrue 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 or about and enroute into and out of any Five Mile Point Speedway event.
By signing this 2012 Five Mile Point Speedway membership Form I acknowledge that I have read the entire form and understand its contents. Five Mile Point Speedway has consent to use driver name and likeness for promotional and souvenir materials. This Five Mile Point Speedway Membership may be revoked at any time for failure to adhere to tour rules, implied or assessed. Everyone entering the pit area must be a full member or temp. (single event member).
Applicant Signature: _____________________________ Date Signed: _______________
Checks may be made payable to: Five Mile Point Speedway,