DRIVER ENTRY FORM (Type or print legibly)

PRE ENTER BY August 28, 2004

$125 full size cars / $75 compact cars

ENTRY THE DAY OF THE EVENT

$150 full size cars / $100 compact cars

DRIVER NAME:

SIGNATURE:

(PRINTED)

PARENT GUARDIAN:

SIGNATURE:

(PRINTED)

ADDRESS:

CITY/ST/ZIP:

PHONE #:

CAR #:

YEAR:

MAKE:

MODEL:

DL#:

SSN#:

DATE:

PIT CREW MEMBERS (Type or print legibly)

PRINT NAME HERE

SIGN NAME HERE

E-Mail Address:

How did you hear about this derby?  TV    Newspaper     Word of mouth       Radio        Web site    

SUBMIT ENTRY FORMS TO:

GARY CHRISTIAN

LES FOSTER

GARRETT RASTOK

Crashin' for the Kids

 c/o ICC

(785) 423-3471

(913) 238-2294

(785) 843-4929

P.O. Box 574

[email protected]

[email protected]

LAWRENCE, KS 66044