2018 Five Mile Point Speedway Membership Application

Please Check One: Driver Membership _____ Crew Membership _____

Applicant Name: ______Car #: ______

(car numbers will not be assigned until fmp office receives receipt of paid membership application)

Applicant Address: ______

(please print and fill out completely)

______Zip Code: ______S.S #: ______-______-______

Racing Division: ______

Birth Date: ____/____/____ Phone Numbers: (h) ______(w) ______

Cell Phone Number: ______Email Address: ______

Driver Website: ______Other Car # Choices: ______

Car Owner: ______S.S #: ______- ______- ______

Owner Address: ______Zip Code: ______

Phone Numbers: (h) ______(w) ______(c) ______

THE PERSON THAT ANY PURSE OR POINT FUND MONIES ARE PAID TO SHOULD BE LISTED

ABOVE AS CAR OWNER WITH COMPLETE INFORMATION PROVIDED.

Every driver wanting to be eligible for point fund money, awards, contingency or bonus awards must file a membership. This includes any or all bonus lap money, giveaways or promotional incentives. The Five Mile Point Speedway Membership Card will be sent to each individual and will provide the lowest discounted pit admission price at each event when offered.

Cost: $55 (prior to March 10, 2018) - $65 (after March 10, 2018)

IN CONSIDERATION of the acceptance of this Five Mile Point Speedway Membership Form, I for myself, my heirs, next of kin, personal representatives and assigns, FOREVER RELEASE, REMISE and FOREVER DISCHARGE and AGREE TO HOLD HARMLESS and INDEMNIFY the promoters presenting races or other events, the owners (lessors) of the premises at which these events are held, the participants, theron, and the owners, sponsors and manufacturers of all racing equipment used in any of these events, the officers, directors, agents, employees and servants of all of them, including officials and Five Mile Point Speedway members, Five Mile Point Speedway, Inc. and 5 Mile Point Promotions, LLC. of and from all liability, claims, action and of possible causes of action whatsoever. Including negligence of any of the foregoing, that may accrue to me or my heirs, next of kin and personal representatives from every and any loss, damage and injury, including death, that may be sustained by my person and property while in or about and enroute into and out of any Five Mile Point Speedway event.

By signing this 2018 Five Mile Point Speedway membership Form I acknowledge that I have read the entire form and understand its contents. Five Mile Point Speedway has consent to use driver name and likeness for promotional and souvenir materials. This Five Mile Point Speedway Membership may be revoked at any time for failure to adhere to tour rules, implied or assessed. Everyone entering the pit area must be a full member or temp. (single event member).

Applicant Signature: ______Date Signed: ______

Checks may be made payable to: Five Mile Point Speedway, P.O. Box 54 – Kirkwood, New York 13795. For further information please phone: (607) 775-5555 or log on to www.5milepointspeedway.com Cell phone and email information is requested to help inform members if the situation of an event rainout or cancellation should occur.