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 1999 Illinois VCA Racing Application

DRIVER INFORMATION

 Name: _____________________________________ Home Phone: ___________________

Address: _____________________________________ Work Phone: ___________________

 City: _____________________________________ State: __________ Zip: ____________

Driver's License # _______________________________ State: __________ Exp: ___________

Insurance Company _______________ Insurance Policy # _______________ Exp: ___________

CAR INFORMATION

Year: ___________ Viper (circle): RT/10 - GTS - GT2 - ACR Other: ____________________

Color: __________ VIN# ________________________________________________________

Circle the class you believe you will be competing in (see "Requirements for Points and Modifications" sheet):

Stock - Super Stock - P repared - Modified - Race      Estimated Total Points: __________

Note: Entrants will be classified by Chief Steward based on information provided above and gathered during tech inspection prior Note:  Entrants will be classified by Chief Steward based on information provided above and gathered during tech inspection prior to competition.  Rollbars, Halon Systems, Fuel Cells are safety items and not deemed modifications.

If you need assistance on points or classification, contact Dave Blankenbaker at [email protected] or 847-798-1104.

(non-Illinois Region members note $50 membership requirement below)

All non-members must join the Illinois V.C.A. to fulfill the insurance requirements.

* Note:  Membership includes, subscription to the club newsletter the Viper Vision, all update letters, admittance to all club events, even discounts on club merchandise.

Make checks payable to VCA Illinois Region………………Total Amount Enclosed =>______________

Refund Policy:  Full refunds will be given to all entrants who cancel 30 days prior to any of the above listed events.  Cancellations with less than 30 days notice will be refunded only if the competition slot can be resold.

Note:  Additional information will be mailed to all registered participants 30 days prior to each event.  Included in the mailings will be (if appropriate) menu selections, car numbers, decals, and any last minute information that the participants need to be aware of.

....................................................................................................................................................................................................................................................................................

Mail Entries To:

VCA Illinois Region

c/o Richard Hamielec

6 N. Elmore

Park Ridge, IL  60068

Region Questions???

Call Seth Palatnik at 312-616-4676 (days)

or Dave Blankenbaker at 847-798-1104 (evenings)

or Rich at 847-698-1442 (evenings)

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Medical Information and Release

(THIS FORM MUST BE COMPLETED, SIGNED, AND RETURNED BY EACH ENTRANT)

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

              (Circle)

Dentures?  YES     NO

Contact Lenses?  YES     NO

Disabilities?  YES     NO      What type? _______________________________________________

Blood Type?___________

Date of last tetanus vaccine?___________________

Medication you are currently taking?______________________________________________________

______________________________________________________

Allergies?______________________________________________________

Any major illness, surgery, or accidents requiring medical treatment within the past two years?

Explain:_______________________________________________________________________

_______________________________________________________________________

In case of emergency, notify:______________________________________________________

Relationship:_____________________Phone:_______________________

All entrants please read and sign below:

1) All entrants must wear Snell SA95 or newer approved helmets. 

2) All entrants shall wear cotton shirts, pants, and socks.  Footwear must be of leather construction (leather athletic shoes accepted).

Note:  Nomex® driving suits, shoes, and underwear are not mandatory unless noted in class rules, but are highly recommended for all classes. 

3) All entrants MUST become Illinois Viper Club of America members as required by insurance coverage provided to the track.  Each new member shall receive, as part of entrants registration package, a membership form which must be completed and returned with event registration form.  Each entrant must also provide a valid drivers license and insurance card to enter the track. 

4) In submitting this application, the entrant agrees to abide by the Illinois VCA regions rules of conduct which pertain to the running of these events, track regulations, and any special rules and regulations which may be established to run these events. 

5) By signing below, I agree to indemnify, release, and hold harmless the Viper Club of America (VCA), the Illinois VCA Region, Illinois VCA Region club Officers, Directors, and club members, and all sponsors from any loss, liability, damage, or cost I may incur arising out of or related to the VCA event(s) whether caused by the negligence of the Illinois VCA Region or otherwise.

6) By signing below, I assume full responsibility for any bodily injury, death, property damage, or other damage or claim arising out of or related to the VCA event(s) whether caused by the negligence of the Illinois VCA Region or otherwise.

I have read and understand the contents of this event application and medical form and indicate this by signing below:

____________________________                 ____________________________________

Print Name                                                                Signature

Date ___________________________________

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