Name _____________________________________ Comp # _______ ________ ________

Address ___________________________________ Email _____________________________________

City ______________________________________ Emergency Contact __________________________

State ______ Zip Code _______________ Emergency Contact phone # ____________________

Phone # ___________________________________

Please fill this form out and mail it to;

Choose 3 competition numbers and we will assign you a number according to your choices and the availability of your number.

We have to have your signature to complete this form. A membership card and stickers will be mailed to you.

I HEREBY RELEASE AND HOLD HARMLESS WITH RESPECT TO ANY AND ALL INJURY, DISABILITY, DEATH, or loss or damage to person or property, WHETHER CAUSED BY NEGLIGENCE OR OTHERWISE, the following named persons or entities: CAM’s MINI ROADRACING ASSOCIATION (CAMMRA), and their directors and officers, Middle Georgia Kart Track (MGKT) , and their directors and officers, and their successors and assigns. To release the above, their officers, directors, employees, representatives, agents, and volunteers from liability and responsibility whatsoever and for any claims or causes of action that I, my estate, heirs, survivors, executors, or assigns may have for personal injury, property damage, or wrongful death arising from the above activities whether caused by active or passive negligence of the named or otherwise.

By signing and accepting your membership number, I agree to hold all named harmless and indemnify them in conjunction with any injury, disability, death, or loss or damage to person or property that may occur as a result of my engaging in any future activities binding to the fullest extent permitted by law.

Signed____________________________________________________________ Date________________