Mohawk Hudson Region

Sanction Number: 05-RS-243-S

June 10,11, 2005

REGISTRAR USE ONLY

Except as modified by the enclosed Supplementary Regulations, this event is held under the SCCA General Competition Rules. Checks payable to Mohawk Hudson SCCA. US funds only

Entry Fee: $250 –

RACE

Mail Entry To:	Nancy Boice	518-885-0841
	10 Pheasant Run	Email: Mohudregs@nycap.rr.com
	Ballston Spa, NY 12020

CAR #

DRIVER INFORMATION
Name: _________________________________________________________	Date of Birth:___________
Street/City/State: ______________________________________________ ________________________________________________________________
Email: ________________________________________________________	Phone No: ________________
SCCA License No: _____________________________________	Region of Record: ___________________________
License Grade: _______________________________________________	Expiration Date: ___________________

CLASS

SPONSOR\ENTRANT INFORMATION
Sponsor: ______________________________________________________
Entrant Name: ________________________________________	SCCA Mbr #: _______
Entrant Address: _____________________________________________ ________________________________________________________________
Rental? From Whom? __________________________________

REGION

CAR INFORMATION
Transponder #: ____________________________________________________	Class: ___SM_______
Make/Model: ______________________________________________________	Color: ___________
Desired Numbers: _________/__________/________

FEE PAID

EMERGENCY CONTACT INFORMATION
Name: __________________________________________________________
Address: ________________________________________________________	At the Track: ______
Phone Number: _________________________________________________	Relationship:_______

CREW INFORMATION	To enter the pit area you must be 16 years of age and an SCCA member with proper credentials per GCR 10.1.4. Only Driver or Crew Chief can modify crew list. Crew Chief is first listed crew member.
Name: ________________________________________________		SCCA Mbr #: ____________
Name: ________________________________________________		SCCA Mbr #: ____________
Name: ________________________________________________		SCCA Mbr #: ____________

MONEY REC'D AT TRACK

SIGNATURE

It is understood and agreed that the undersigned and the car described above are to compete under the General Competition Rules and these Supplementary Regulations

Driver:

_________________________________

Entrant:

________________________________

DRIVER MEDICAL INFORMATION

REGISTRAR USE ONLY

Name: _______________________________	Age:____	Hemophiliac:	__
Address: _____________________________		Epileptic:	__
Blood Type: ___________________________	Tetanus Date:	Asthmatic:	__
Current Medications: ___________________ ______________________________________	__/__/__	Dentures:	__
Allergies: _____________________________		Diabetic:	__
Special Conditions: ____________________		Contacts:	__
Physician/address/phone:________________ ______________________________________		Organ Donor:	__

RACE ___________

CAR # ____________

EMERGENCY CONTACT

Notify Whom: ______________________________	Phone: ___________
Address: __________________________________
At Track: __________________________________	Mbr #: ___________

CLASS __________

TIMING & SCORING

Car Make/Model: ________________________________________________	Color:___________
Driver Name: ____________________________________________________
Mbr#: __________________________________________________________	Region: _________
Address/City/St: _________________________________________________ ________________________________________________________________
Sponsor: _______________________________________________________
Transponder #: ____________________

RACE_____________

CAR #____________

CLASS ______SM_____

Make Checks payable to Mo-Hud SCCA

Mail Entry to: Nancy Boice

10 Pheasant Run

Ballston Spa, NY 12020

Worker Contributions- Contributions to the workers fund are greatly appreciated. You may just add any amount you wish to your check or make a separate donation at Registration. Mohawk Hudson Region matches all driver donations and distributes them via a raffle at the end of the day. Donors are recognized in our program unless anonymity is requested.

Visa and Master Card accepted online and at the track.