[ ] Check      [ ]Cash     *All car numbers must be approved; the PAS reserves the right to reassign the number. 
Driver        $50              **All cars must pay $40.00 entry fee per race. (Money will be collected at pill pick) 
General     $50

2013 PASSCAR MEMBERSHIP

[ ] Super Stocks   [ ] Street Stocks   [ ] Factory Stocks   [ ] Modifieds    [ ] Sport Mods    [ ] General

Car #_________
 
_________________________________________________________________________________________________
 
Name                                
             Phone Number                                                               Cell Phone

                                                                                                                                                                         Street                                 City                                 State                                                     Zip

                                                                                                                                                                        
Social Security Number                        Birth Date                                     
                          Occupation

E-Mail Address                                                                                                                                             

Emergency Contact                                                                                                                                     
                                  Name                                    Address                                                      Phone

Sponsors (list three)____________________________________________________________________________

ANY driver, crew, member, spectator or car may be banned from the facility for whatever reason and period the management desires.
 

In consideration of PASSCAR and/or their designee granting to me a license to participate in sanctioned events, and to complete for prize money, or other remunerationís, or to enjoy participation in scheduled sporting events, I hereby grant to said PASSCAR, et al. and/or their designee:

FIRST:  All fees, salaries or other remuneration, including residuals derived from any movie items, television, radio, advertising or other entertainment media derived from my activities as a participant in any PASSCAR sanctioned event.

SECOND:  The exclusive right to publish, sell or use in any fashion, photographs of me or my equipment, with remuneration or notice to me.

THIRD:  A complete and unconditional release on behalf of myself and heirs for any injuries sustained by me while participating in any sanctioned event, or any damage to my property sustained while participating in any sanctioned event.

As a condition under which PASSCAR agrees to issue me a license to participate in sanctioned events, I affirm the following representations:

FIRST:  My participation in any sanctioned event shall be on a voluntary basis, in which event I shall be acting solely for myself as an independent contractor.  I will not act as an agent, servant of employee of PASSCAR or any other person or organization if I participate in any event.  

SECOND:  If, as a result of my voluntary participation in any sanctioned event, I win any prize money ore receive other remunerationís, I do so as an independent contractor, and will maintain all necessary financial records and make all necessary tax returns. 

THIRD:  As a voluntary participant in any sanctioned event, acting solely on my behalf as an independent contractor, I recognize the fact that PASSCAR does not provide workersí compensation insurance, unemployment insurance, unemployment disability insurance, federal old-age survivors insurance, state or federal taxes, or any other insurance.

FOURTH:  As a voluntary participant in any sanctioned event, I fully recognize the possibility of injury to my person and damage to my property, and I freely assume this risk as a participant in any sanctioned event.  Further, I hold PASSCAR and its affiliates harmless in the event of such injury to my person or damage to my property.

FIFTH:  I have read and understand this application for a participantís license.  I fully understand the application contains a general release to all persons in any way connected with a sanctioned event, for any personal injuries I sustain or any damage to my property. 

SIXTH:  I am 18 years of age or older or have filed with PASSCAR a Minorís Release Form approved by my parents or guardian.

I HAVE READ AND FULLY UNDERSTAND THIS WAIVER AND RELEASE OF LIABILITY AND WAIVER OF INDEMNITY AND I KNOW AND UNDERSTAND THAT MY SIGNATURE ON THIS FORM RELEASES PASSCAR, TOGETHER WITH ITS OFFICERS, DIRECTORS, OFFICIALS, REPRESENTATIVES, AGENTS AND AFFILIATES FROM ANY AND ALL LIABILITY, INCLUDING NEGLIGENCE, AND I FREELY AND WILLINGLY CONSENT TO THIS WAIVER AND RELEASE OF LIABILITY AND WAIVER OF INDEMNITY AGREEMENT.
 

SIGNED:                                                                       DATED:                                                           

Perris Auto Speedway, 18700 Lake Perris Drive, Perris, CA  92571, Phone:  (951) 940-0134, Fax:  (951) 940-0634