ENTRANT MEMBERSHIP & INSURANCE BENEFIT PLAN CONTRACT

               2002 Dixie Motor Speedway Membership Registration           *ONE FORM PER DIVISION

In order to collect winnings driver or owner must show their card, only driver or owner may .pick up winnings unless prior arraignments have been made!                                          

.Type of membership (please check one)

            Driver              Driver/Owner -Mandatory for all Dixie drivers who will participate in points competition at Dixie Motor Speedway  [                 Owner (see back)]

Late Model $35; Mods $35; Factory Stock $30;Fig 8 $30; Super Mini-Trucks $20 .(circle one) if applying for more than one division must fill out add'l registration form                                                                                                                                                                                  .How many years Racing?_________ Rookie (have you ever driven in this division before at Dixie) ;;;;;;;;;;if yes how many races?____

NAME, Last _____                    ___        ______ First _______             ______ __ M                     Age __ ___

Residence Address: ____                                                            ___ APT #             LOT #                    

City _________________                                        _____ State ______    __ Zip                                

Driver’s License #_______________________________________

Telephone #’s Residence (             )                                         Work (         )                                        

Date of Social Security #                                                                                        

Birth date                /                     /                            spouses name                                                            

E-mail _________________________________________@ _____________.com

Web Site   Address___________________________________________

Employment:                                                    l Employer                                                                       

Employer Address or city Occupation                                                                                                     

Date of Last Physical                                                  Physical Condition                                                 

Any Handicaps or  Disabilities?*YES / NO  *If Handicaps or Disabilities exist, describe:                        

 Health Insurance:                                                     Type: Group or Individual       Any allergies: yes / no

BENEFICIARY STATEMENT: I hereby designate and name as Beneficiary Spouse Parent Other

Name                                 address                                     city/state                     phone # (         )                            

illCar Owner information Driver will receive 1099 unless back side of this form is fill out

AGREEMENT

.....  

Racing is a Dangerous Sport. Injury and/or death can result from racing related activities. As a participating car owner, driver, spectator, mechanic, employee, official, sponsor or independent contractor, I agree that the track & pit areas are in safe condition if I take part in racing activities, and that I have been given no implied or expressed warranty of safety.

I understand that my signature along with the registration fee, and acceptance of this application by the D.M.S. makes me a member of the D.M.S. club and entitles me to the benefits thereof.

I understand that as a registered member of D.M.S., I and my heirs and assigns will be entitled to the Competitor Accident Insurance Policy procured by D.M.S. for accidental injury or death sustained in D.M.S. events, provided proper notice is given to D.M.S. The policy coverages in force shall be considered the limit of liability of D.M.S. for injury or death occurring to me in any D.M.S. event.

I also understand that as a member of D.M.S. I am eligible to compete for the drivers point championship and point fund. I understand that in order to receive point fund winnings, I must attend the annual awards banquet.

I certify that I am an independent contractor and not an employee of D.M.S. I assume all financial responsibilities including, but not limited to, withholdings tax, income tax & workmen’s compensation insurance with regard to any monies received from D.M.S.

Any driver or crewmembers leaving their own pit area and involved in a fight will be immediately fined $250.00. If that amount is not paid immediately, the fine will be raised to $500.00, and that individual, as well as driver will not be allowed in pit area until fine has been paid. If driver refuses to pay fine immediately all points will be forfeited for that night. Unsportsman like conduct will not be tolerated under any circumstance and will result in immediate removal, suspension and/or fine from D.M.S.

Any dispute, controversy or claim involving the undersigned member shall be settled in accordance with existing and/or amended rules and regulations of D.M.S., and I agree to accept the decisions rendered in the process. Disputed decisions may be appealed, in writing to the Speedway office within 5 days. Upon appeal, D.M.S. decisions are final. Drivers agree to be responsible for ALL crewmembers, registered or unregistered. D.M.S. reserves the right to adjust division rules, including weight, in the interest of fair and competitive racing. D.M.S also reserves the right to amend or modify Speedway policies, rules and regulations as may be needed.

I consent to the use of my name and/or pictures of me and my car for publicity, advertising and endorsements, and relinquish any rights to photos taken in connection with racing activities and consent to the publication or sale of such photos by D.M.S.

I AGREE TO ABIDE BY ALL TERMS AND CONDITIONS OF THIS AGREEMENT AND THE REQUIREMENTS OF THE RULES AND REGULATIONS OF DIXIE MOTOR SPEEDWAY AS NOW PUBLISHED, OR AMENDED IN THE FUTURE. I AGREE NOT TO ENGAGE IN ANY ACTIVITY THAT WOULD DISTRUPT OR INHIBIT RACING AT D.M.S. BY MY SIGNATURE BELOW, I CERTIFY THAT I HAVE READ AND FULLY UNDERSTAND THIS AGREEMENT. I AGREE THAT IN THE EVENT I BREACH THIS AGREEMENT, I AM LIABLE FOR ACTUAL AND LIQUIDATED DAMAGES SUSTAINED BY THE SPEEDWAY AS A RESULT OF SUCH BREACH.

Dated:                      Day of                      ,200          legal signature:                                                    

                                                                                      Witness:                                                                 

If applicant is under 18 yrs old, a minor/parent release must be executed & filed w/this application

                                        Please return this form signed, dated and check or money order to:                                             Dixie Motor Speedway - 10945 Dixie Hwy; Birch Run, MI 48415                   989.624.9778; Fax 989.624.9570

 

 

1099 TAX INFORMATION (FOR CAR OWNERS)

2002 Dixie Motor Speedway Registration OWNER Form

Car Owner-1099 recipient must complete this form if different from driver information

If you are a driver/owner & will receive 1099 & if you have completed the front side you DO NOT have to fill this side out.

ENTRANT CAR OWNER AND INSURANCE BENEFIT PLAN CONTRACT

 

Owner - Mandatory for all Dixie owners whose drivers will participate in points competition at Dixie Motor Speedway

Late Model $35.00; Modified $35.00; Factory Stock $30.00; Figure 8 $30.00; Super Mini-Trucks $20.00

NAME, Last _____                    ___        ______ First _______             ______ __ M                     Age __ ___

Residence Address: ____                                                            ___ APT #             LOT #                    

City _________________                                        _____ State ______    __ Zip                                

Driver’s License #_______________________________________

Telephone #’s Residence (             )                                         Work (         )                                        

Date of Social Security #                                                                                        

Birth date                    /                     /                         spouses name                                                            

E-mail _________________________________________@ _____________.com

Web Site   Address___________________________________________

Employment:                                                    l Employer                                                                       

Employer Address or city Occupation                                                                                                     

Date of Last Physical                                                  Physical Condition                                                 

Any Handicaps or  Disabilities?*YES / NO  *If Handicaps or Disabilities exist, describe:                        

 Health Insurance:                                                     Type: Group or Individual       Any allergies: yes / no

BENEFICIARY STATEMENT: I hereby designate and name as Beneficiary Spouse Parent Other

Name                                 address                                     city/state                     phone # (         )                            

 

AGREEMENT

Racing is a Dangerous Sport. Injury and/or death can result from racing related activities. As a participating car owner, driver, spectator, mechanic, employee, official, sponsor or independent contractor, I agree that the track & pit areas are in safe condition if I take part in racing activities, and that I have been given no implied or expressed warranty of safety.

I understand that my signature along with the registration fee, and acceptance of this application by the D.M.S. makes me a member of the D.M.S. club and entitles me to the benefits thereof.

I understand that as a registered member of D.M.S., I and my heirs and assigns will be entitled to the Competitor Accident Insurance Policy procured by D.M.S. for accidental injury or death sustained in D.M.S. events, provided proper notice is given to D.M.S. The policy coverages in force shall be considered the limit of liability of D.M.S. for injury or death occurring to me in any D.M.S. event.

I also understand that as a member of D.M.S. I am eligible to compete for the drivers point championship and point fund. I understand that in order to receive point fund winnings, I must attend the annual awards banquet.

I certify that I am an independent contractor and not an employee of D.M.S. I assume all financial responsibilities including, but not limited to, withholdings tax, income tax & workmen’s compensation insurance with regard to any monies received from D.M.S.

Any driver or crewmembers leaving their own pit area and involved in a fight will be immediately fined $250.00. If that amount is not paid immediately, the fine will be raised to $500.00, and that individual, as well as driver will not be allowed in pit area until fine has been paid. If driver refuses to pay fine immediately all points will be forfeited for that night. Unsportsman like conduct will not be tolerated under any circumstance and will result in immediate removal, suspension and/or fine from D.M.S.

Any dispute, controversy or claim involving the undersigned member shall be settled in accordance with existing and/or amended rules and regulations of D.M.S., and I agree to accept the decisions rendered in the process. Disputed decisions may be appealed, in writing to the Speedway office within 5 days. Upon appeal, D.M.S. decisions are final. Drivers agree to be responsible for ALL crewmembers, registered or unregistered. D.M.S. reserves the right to adjust division rules, including weight, in the interest of fair and competitive racing. D.M.S also reserves the right to amend or modify Speedway policies, rules and regulations as may be needed.

I consent to the use of my name and/or pictures of me and my car for publicity, advertising and endorsements, and relinquish any rights to photos taken in connection with racing activities and consent to the publication or sale of such photos by D.M.S.

I AGREE TO ABIDE BY ALL TERMS AND CONDITIONS OF THIS AGREEMENT AND THE REQUIREMENTS OF THE RULES AND REGULATIONS OF DIXIE MOTOR SPEEDWAY AS NOW PUBLISHED, OR AMENDED IN THE FUTURE. I AGREE NOT TO ENGAGE IN ANY ACTIVITY THAT WOULD DISTRUPT OR INHIBIT RACING AT D.M.S. BY MY SIGNATURE BELOW, I CERTIFY THAT I HAVE READ AND FULLY UNDERSTAND THIS AGREEMENT. I AGREE THAT IN THE EVENT I BREACH THIS AGREEMENT, I AM LIABLE FOR ACTUAL AND LIQUIDATED DAMAGES SUSTAINED BY THE SPEEDWAY AS A RESULT OF SUCH BREACH.

Dated:       Day of             ,200    legal signature:                    

                                                                                                                          Witness:                       

If applicant is under 18 yrs old, a minor/parent release must be executed & filed w/this application

                                        Please return this form signed, dated and check or money order to:                                 Dixie Motor Speedway - 10945 Dixie Hwy; Birch Run, MI 48415                   989.624.9778; Fax 989.624.9570

 

Please return this form signed, dated and check or money order to: Dixie Motor Speedway - 10945 Dixie Hwy; Birch Run, MI 48415

989.624.9778; Fax 989.624.9570

 
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