Event Title and Date: ___________________________________________________
Driver Name: _____________________________ Tel. (H): _____________________
Street Address: ____________________________Tel. (W): _____________________
City, State, Zip: ________________________________________________________
E-MAIL: __________________________________________
Yes: ___ No: ___ I hold a currently valid State drivers license.
Yes: ___ No: ___ My 2004 VSCCA membership is current.
Yes: ___ No: ___ I am 18 years of age or older.
Yes: ___ No: ___ I have satisfied the VSCCA Driver Qualification Committee (DQC)
requirements to be placed on the list
of approved drivers.
Yes: ___ No: ___ I am in currently in good standing with the DQC.
Yes: ___ No: ___ I have had a comprehensive medical exam within the last 24 months.
Yes: ___ No: ___ I have no physical or mental problems to prevent me participating.
Yes: ___ No: ___ I recognize that my car must be technically examined for compliance
with club safety requirements as well
as Car Classification Committee requirements as to car
preparation prior to my participation.
Yes: ___ No: ___ I have a VSCCA logbook for this car and have satisfied the VSCCA car
classification committee as to its VSCCA
eligibility.
Yes: ___ No: ___ I understand that this is a vintage event in which the primary and only
real objective is the safety of all
participants, and the preservation of our vintage cars, and
I agree to drive in accordance with that philosophy, and to be excluded
from the
remainder of the event if the event chairman in his sole discretion finds that I am not in compliance.
Owner of car: ___________________________ Tel.: ____________________________
Street Address: __________________________ Tel.: ____________________________
City State, Zip: ___________________________________________________________
Name and phone number of person to contact in case of emergency__________________
Car Year: ______ Make: _________ Model: ________ Color:_______ Ser #:_________
Lap time at this track: _______ Indicate Lime Rock lap time, or any track you know if
you don't
know your lap time at this track: _____________________________________
Class: (PW, Pres, U2, O2, SR, F): ____________(You may be placed in a different class)
Actual Displacement (cc): ____________ VSCCA permanent number:______________
Actual tire size (f):_________ (r):___________ Actual tread width (f):_______(r):______
Actual wheel size, Width (f): ________ (r): ________ Diameter (f): _______ (r): _______
(If applicable) Number of dinners _______at $ ___________ per person = $ __________
By signing this form, I acknowledge and certify that all of the above information is true,
and I understand that
participating in a vintage speed event such as this one is a
mentally and physically demanding activity that involves risk.
I assert and certify that I knowingly
and willingly assume said risk of participating in this VSCCA speed event. I also
acknowledge and certify that I have had a comprehensive medical exam within the past 24 months,
and that I have no physical
or mental problems that would prevent me from safely participating
in this VSCCA speed event.
Signature: Driver _____________________ Owner __________________________
Please refer to event announcement for the fee for this event, make checks payable to
"VSCCA Inc.", and forward to the event Chairman
listed in the Event Announcement.
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© AutoPhotos 2004 - Ed Hyman
Consulting
