MEMBERSHIP APPLICATION

(Please print clearly)

LAST NAME: ____________________________           FIRST NAME:  ___________________________

DATE OF BIRTH:  ________________________________________________________________

MAILING ADDRESS:  _____________________________________________________________ 

HOME PHONE: ______________________        BUSINESS PHONE: _______________________

E-MAIL ADDRESS FOR NEWSLETTERS:  _____________________________________________

MEDICAL INSURANCE NUMBER:  ___________________________________________________

BLOOD TYPE:  _________________________            ALLERGIES (if known): _____________________

VALID DRIVER’S LICENSE NUMBER:  ________________________________________________

IN CASE OF EMERGENCY, PLEASE CONTACT (to be filled in by ALL applicants)

NAME: _________________________________________________________________________

ADDRESS:  _____________________________________________________________________

PHONE NUMBER:   __________________________                                 Continued on back ………

CAN-AM MIDGET RACING CLUB

MEMBERSHIP FEES

                                                                                    CAN.                U.S.                  CHECK

*Owner & Car Registration                                           $100                 $80                   _______

Driver                                                                           $ 25                  $20                   _______

Crew Member                                                               $ 25                  $20                   _______

Associate                                                                     $ 25                  $20                   _______

Official                                                                          $ 25                  $20                   _______

(*includes Driver if same as Owner)

Annual dues for membership are due and payable on January 1^st.

I, the undersigned member in good standing agree to abide by all rules and regulations of the Can-Am Midget Racing Club Inc., now published and hereinafter modified.  I understand that this membership is non-transferrable and it shall be revoked in the event of misuse or if my actions are not in accordance with the rules and regulations of the Can-Am Midget Racing Club Inc., or are detrimental to the sport of auto racing.  I am aware of the dangers of auto racing and assume all risks involved.  In signing this form, I agree further that the Can-Am Midget Racing Club Inc. not be held for any liability by either myself, wife, husband, heirs or any others in the event of my injury or death.  I agree to accept the insurance provisions of the Can-Am Midget Racing Club Inc.  I will accept the decisions of the membership as final in the decisions they find.  In submitting this application for membership, I realize that I may be suspended for any infractions of the rules or regulations at any time if so deemed by the Board.  The Can-Am Midget Racing Club Inc. and/or its sponsors or suppliers have my permission to use my name and/or photograph in any promotional publications or event.  I further certify that all the above statements made by me are true.

Signature:                                                         Date:

_____________________________                   ญญญญญญญญญญญญญญญญญญญญญญญญญญญญญญญญญญญญญญญญญ_______________________________

Note:  Can-Am Midget Racing Club membership is not valid until declaration is signed, dated by the member and the appropriate fee attached and accepted by a club executive member.

Accepted By:  ________________________            Date:  __________________________

Title:  _______________________________   Card # Issued:  ___________________

Please mail membership forms to:                       Randy May, PO Box 294, Mt. Hope ON  L0R 1W0

(on or before February 1, 2004)