2013 Oglethorpe Speedway Park
Driver License Application

$30 Fee

Division:    ___Late Model    ___Street Stock    ___Pure Stock    ___Mini Stock    ___440 Series


DRIVER INFORMATION

Full Name:___________________________________________________     Nickname:_________________________________

Address:__________________________________________________________________________________________________

City:___________________________________________    State:________________________    Zip:_____________________

Social Security Number:____________________________________    Birthdate:______________________________________

E-Mail Address:__________________________________________________________________________________________________

Home Phone Number:___________________________________    Cell Phone Number:_______________________________

Personal Insurance Company:_________________________________    Policy Number:_______________________________

In Case of Emergency, Notify:________________________________________________________________________________

Relationship:___________________________________________    Phone Number:____________________________________

TEAM INFORMATION

Car Number:______________    Year, Make & Model of Race Car:________________________________________________

Sponsors:__________________________________________________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

Crew Members:__________________________________________________________________________________________________

__________________________________________________________________________________________________________

Remit to: Oglethorpe Speedway Park - PO Box 687 - Pooler, GA 31322

LICENSE AGREEMENT

CONTRACT:  I am an independent contractor assuming all responsibility for money received as result of my speedway activities including income tax, FICA, workers compensation and withholding taxes.  I am not an employee, servant or agent of Oglethorpe Speedway Park.

BENEFITS:  I agree that myself, Executors and assigns will be entitled only to benefits of the Competitor Accident Policy procured by the Speedway for accidental injuries which are a result of external, violent and visible means sustained in Speedway events.  The foregoing shall consitute the limit of liability of Oglethorpe Speedway Park for such injuries occuring to me in any Speedway event provided proper notification is given.

COMPLIANCE:  The undersigned agrees to abide by all rules and regulations of the Speedway now published or hereinafter modified.  The undersigned acknowledges having read, understood and voluntarily understands this agreement and the rules of the Speedway and agrees to abide by the current rules and regulations of Oglethorpe Speedway Park now published and hereinafter modified.  In consideration of the acceptance by the Speedway of this agreement, the undersigned recongnizes his/her acceptance to all Oglethorpe Speedway Park official's decisions, penalties and suspensions with the possibility of the membership being revoked at any time when this agreement has been breached.  The undersigned understands that stock car racing can be a dangerous sport and the pit area is restricted to those persons involved with the race car.  The undersigned accepts full responsibility for injury to themselves and releases Oglethorpe Speedway Park from all liability resulting from any injury.

ADVERTISING RELEASE:  The undersigned consents to the use of his/her name, pictures or video of himself/herself and their car for publicity, advertising and endorsements both before and after the events, and relinquishes any rights to photos or footage taken in connection with events and consents to the publication of sale of suc photos as the Speedway 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 this Speedway 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 ALL THE RULES SET FORTH BY OGLETHORPE SPEEDWAY PARK.

X    Your Signature:______________________________________________    Date:________________________________