Lime Rock Park

John Stim Memorial Regional Race

 

Mohawk Hudson Region

Sanction Number: 06-R- 174 -S

 

July 4th, 2006

 NARRC &  NYSRRC

 

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: $ 260.00

  SRF, FSCCA and SRSCCA  add $10 per race Compliance Fee

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: __________

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/Year:  ________________________________________________

Color:___________

Driver Name: ____________________________________________________

 

Mbr#:  __________________________________________________________

Region: _________

Address/City/St: _________________________________________________

________________________________________________________________

 

Sponsor:  _______________________________________________________

 

Transponder #:  ____________________

 

 

 

 

 

RACE_____________

 

 

CAR #____________

 

 

CLASS ___________

 

 

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 Mastercard accepted online and at the track