2013 USAC Application for
Membership
 
* PLEASE FILL OUT THE FORM COMPLETELY
 
First Name: ______________________________________________________________________________________________________
Last Name: ______________________________________________________________________________________________________
Address: ________________________________________________________________________________________________________
City: _____________________________________________________ State: _________________________________ Zip: _____________
Date of Birth: ______________ Email: __________________________________________________________________________________
Online Password Request: ____________________________________________________________________________________________
Home Phone: ______________________________________________ Cell Phone: ______________________________________________
 
Insurance Beneficary (Someone other than yourself)
 
First Name: _______________________________________________________________________________________________________
Last Name: _______________________________________________________________________________________________________
Phone: ___________________________________________________________________________________________________________
 
Please Select License Type(s) on Page 2
All Car Entrants must fill out page 3
All Applicants must agree to policies on pages 4-6
All Applicants must complete page 7
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Series License Type Cost Requested (Please check all that apply)
Super License Driver $900.00  
       
Silver Crown Driver $500.00  
  Entrant $500.00  
  Driver/Entrant $800.00  
  Driver Dirt Only $250.00  
  Driver Pavement Only $250.00  
  Crew $150.00  
       
National Sprint Driver $350.00  
  Entrant $350.00  
  Driver/Entrant $500.00  
  Crew $150.00  
       
ALL Western Sprint Divisions Driver $250.00  
Including: CRA, Western Classic Entrant $250.00  
WC360, Western Sprint Driver/Entrant $400.00  
Southwest Sprint Crew $150.00  
       
National Midget Driver $350.00  
  Entrant $350.00  
  Driver/Entrant $500.00  
  Crew $150.00  
       
DMA Midget Driver $250.00  
  Entrant $250.00  
  Driver/Entrant $400.00  
  Crew $150.00  
       
Western Midget Driver $250.00  
  Entrant $250.00  
  Driver/Entrant $400.00  
  Crew $150.00  
       
Ignite Midget Driver $250.00  
  Entrant $250.00  
  Driver/Entrant $400.00  
  Crew $150.00  
       
USA Membership Jeffrey Hougue Realtor.com $35.00  
  Action Track USA    
       
USAC 600 Sprints Driver $150.00  
       
Others Race Official $150.00  
  Sponsor $150.00  
  Media $150.00  
  Fan Membership $150.00  
 
 
 
 
 
 
 
 
 
 
Must be filled out for all car entrants
Car Entrant Information:
Car 1
Series for Competition: ____________________________________________________________________________________________
Desired 2013 Car Number: _________________________________________________________________________________________
Car Entrant Name (As Listed For Points): ______________________________________________________________________________
Chassis Make___________________________________________________________________________________________________
Engine Make____________________________________________________________________________________________________
Sponsor Name __________________________________________________________________________________________________
PAYEE INFORMATION: (Must Be Filled Out To Be Paid)
First Name: _____________________________________________________________________________________________________
Last Name: _____________________________________________________________________________________________________
Address: _______________________________________________________________________________________________________
City: ____________________________________________________ State: _______________________________ Zip: ______________
TAX ID or SS#:__________________________________________________________________________________________________
 
Other Same Series Cars To License - Additional Memberships Fees Will Apply
Car 2
Series for Competition: ______________________________________________________________________________________________
Desired 2013 Car Number: ___________________________________________________________________________________________
Car Entrant Name (As Listed For Points): ________________________________________________________________________________
Chassis Make_____________________________________________________________________________________________________
Engine Make______________________________________________________________________________________________________
Sponsor Name ____________________________________________________________________________________________________
 
Car 3

Series for Competition: ______________________________________________________________________________________________

Desired 2013 Car Number: ___________________________________________________________________________________________
Car Entrant Name (As Listed For Points): ________________________________________________________________________________
Chassis Make_____________________________________________________________________________________________________
Engine Make_____________________________________________________________________________________________________
Sponsor Name ____________________________________________________________________________________________________
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Please check all boxes
Application for annual membership and / or license certifications, acknowledgment & authorization for publicity usage.
 
APPLICATION. I hereby apply for a license from the United States Auto Club, Inc. (USAC) of the type specified on this license. I certify that the information supplied by me on this license is true and correct and may be relied upon by USAC. I understand that a license is subject to the Official Competition Rules of USAC. If my application is approved by USAC I agree to be bound by such Official Competition Rules and agree that decisions by USAC and/or interpretation of rules will be governed exclusively by the administrative review and appeal procedure set forth in such rules.
 
CERTIFICATIONS. I certify that I am 18 years of age or older. (In consideration of the acceptance by USAC of this application an applicant who has achieved the age of 18 but has not achieved the age of majority in the state where the applicant resides, must have a parent or natural guardian sign this application, authorization, release and waiver of liability.) I certify that I am not an employee of USAC. I certify that I will assume all responsibility for all charges, premiums and taxes, if any, payable on any funds that I may receive as a result of my competitive activities, including without limitation, social security taxes, unemployment insurance taxes, compensation insurance, income taxes and withholding taxes.
 
ACKNOWLEDGMENT. I hereby acknowledge and agree that I have no right, property or interest in any radio or television broadcast, motion pictures, still photographs, tape, or sound reproductions taken, made, transmitted, reproduced, or used for any USAC sanctioned event, including practice, qualifications, the race, awards ceremonies or other event associated with the racing event, and also including but not limited to pictures and sound of me alone or with other persons, with or without racing equipment, as well as any and all receipts there from, and any transcription thereof.
 
AUTHORIZATION FOR PUBLICITY USAGE. I agree that USAC, or its assigns, on a non-exclusive basis, may use my name and pictures, including pictures of my racing equipment and pictures taken at any USAC sanctioned event for publicity purposes, but not for commercial sponsorship of any product.
 
I have read and agree to the Authorization for Publicity Usage.
 
 
Annual release and waiver of liability, assumption of risk & indemnity agreement.
 
In consideration of being granted a license and in consideration of being permitted to enter for any purpose any "restricted area" (herein defined as including but not limited to the racing surface, pit areas, infield, garage areas, and all walkways, roadways, concession areas and other areas appurtenant to any area where any activity related to the competitive racing event shall take place)":
 
RELEASE AND WAIVER OF LIABILITY: I, for myself, my heirs, next of kin, personal representatives and assigns, hereby release, waive, discharge and covenant not to sue the United States Auto Club, Inc. (USAC), its successors and assigns, the race organizer presenting USAC sanctioned events, the owners and lessees of premises on which USAC sanctioned events, including car owners, drivers, mechanics, pit crews, and any persons in any restricted area, promoters, sponsors, advertisers, manufacturers of all racing equipment upon the premises, and the officers, directors, officials, representatives, agents and employees of all of them (all of whom for the purposes herein are referred to as "releasees") from all liability, loss, claims, demands, possible causes of action, court costs, attorneys' fees and other expenses arising from any lawsuit that may otherwise accrue from any loss, damage or injury (including death) to my person or property in any way resulting from, or arising in connection with, or related to, any sanctioned event, and whether arising while engaged in competition or in practice or preparation therefore, or while upon, entering or departing from said premises, from any cause whatsoever including without limitation, the failure of anyone to enforce rules and regulations, failure to make inspections, or the negligence of releasees or other persons.
 
ASSUMPTION OF RISK. I know the risk to myself and property, both from known risk and unanticipated risk, while in or upon the restricted area or while participating or assisting in a sanctioned event, and I do so willingly, voluntarily and in reliance, not upon the property, equipment, facilities and existing conditions furnished by others, but upon my own judgment and ability, and I thereby assume all risk of loss, damage or injury (including death) to myself and my property from any cause whatsoever and whether or not attributable to the negligence of releasees or other persons.
 
INDEMNITY AGREEMENT. I hereby agree to indemnify and hold harmless the releasees and each of them from any loss, liability, damage or cost they may incur due to the presence of the undersigned in or upon the restricted area, whether caused by the negligence of releasees or other persons.
 
I have read and agree to the Annual Release and Waiver of Liability.
 
 
 
 
Substance Abuse Policy
 
Preamble
 
The United States Auto Club "(USAC)" strives to maintain the integrity of the Club and its Events (Event as defined in the USAC Rule Book). USAC is concerned about the problem of substance abuse in America's society and, more particularly, the threat that this may create for the safety of our racing participants. The use of illegal drugs at any time, or the use of alcohol during an Event, and even the proper use of certain medications during an Event, may endanger the internal and external perception of the Club. Such conduct cannot be permitted by USAC.
 
With the above in mind, this Substance Abuse Policy ("Policy") has been adopted. It applies to drivers, mechanics and crew members (hereinafter "Competitor" or "Competitors"), as well as to USAC officials (hereinafter "Official" or "Officials"). It may also be applied to other participants in an Event as USAC deems appropriate in its sole discretion.
 
1. Prohibited Acts and Substances
A. Prohibited Substances
For the purpose of this Policy, "prohibited substances" are substances that are determined by USAC, in its sole discretion, to adversely affect the integrity of the Club or well-being of Competitors or Officials, or others, or the performance of a Competitor or Official in connection with an Event. "Prohibited substances" include, but are not limited to, illegal drugs such as marijuana, cocaine, and hallucinogens. Furthermore, for purposes of the foregoing, the definition of "prohibited substances" also includes, without limitation, paraphernalia associated with illegal drug use and mind-altering and/or addictive substances, which are not sold as drugs or medicines, but are used or marketed for their mind or behavior-altering effect. USAC may make a determination that any particular substance is a prohibited substance at any time, in its sole discretion. Competitors and Officials are prohibited from using, possessing, purchasing, selling, manufacturing and/or participating in the distribution of prohibited substances, regardless of the amount, at any time.
 
B. Proper and Improper Use of Prescription and Over-the-Counter Medications/Substances
USAC recognizes that there are many prescription and over-the-counter medications that serve essential or beneficial purposes for the health and well-being of Competitors and Officials, and nothing in this Policy is intended to discourage the proper use of these medications. Just as importantly, however, it must be recognized that there are some medications that, even when properly used, may adversely affect a participant's fitness to be involved in a racing event or events. For example, many types of cough medicines contain codeine, which is a potent narcotic that may result in drowsiness or diminished alertness.
 
Misuse and the illegal use, acquisition or distribution of a prescription or over-the-counter medication or any mind-altering or addictive substance by an individual is prohibited and, for these purposes, is deemed to be the use of such a medication in a manner which is inconsistent with the instructions provided by the manufacturer, pharmacist and/or the prescribing physician. In addition, illegal use, acquisition, or distribution of any prescription drug, over-the-counter medication, or any mind-altering and/or addictive substance are strictly prohibited at any time. For example, it is a violation of this Policy for an individual to use a prescription or over-the-counter medication in a manner that is not consistent with the intended and medically-prescribed use.
 
To the extent that USAC in its sole discretion determines that the use of any prescribed medication or other substance, including properly prescribed prescription drugs and properly used over-the-counter medications, causes an individual to have a diminished or impaired ability to perform his or her duties on the day of an Event, those substances shall be deemed to be prohibited substances for purposes of this Policy.
 
 
 
C. Alcohol
No Official or Competitor may consume alcohol in the hours prior to or during an Event involving on track activity, nor may any Official or Competitor be under the influence of alcohol at any Event. "Under the influence," for purposes of this Policy means that in the sole judgment of USAC the Official or Competitor has an impaired ability due to alcohol consumption to conduct himself or herself as USAC would expect at an Event. Nothing in this paragraph shall preclude USAC from determining that a Competitor or an Official with any alcohol usage, however minimal, is physically unfit for driving, participating, or officiating in an Event. An alcohol test by breathalyzer, blood test, or other scientifically-acceptable method may be performed if deemed appropriate by USAC at its sole discretion. In connection with the foregoing, USAC may take such action as it deems appropriate.
 
2. Targeted Testing for Reasonable Suspicion of Drug/Alcohol Use
 
USAC may require a Competitor or Official to submit to a test or tests, including without limitation, urine, blood, saliva, hair, breath tests, and/or any other scientifically-acceptable method of testing when USAC has reasonable suspicion that the Competitor or Official has violated any part of this Policy or that he/she has diminished ability to perform due to the use of any prohibited substance or alcohol. Examples of the conditions, observations and/or reports that may result in "reasonable suspicion" include, but are not limited to, the following:
 
A. When a Competitor or Official is found or observed in possession of illegal drugs or drug paraphernalia at any time;
   
B. Observation of signs, symptoms and/or behaviors that may be associated with the use of prohibited substances or alcohol including, but not limited to:
 
1. Direct observation of an individual engaged in drug-related or alcohol-related activity.
2. Discovery or presence of prohibited substances or alcohol in an individual's possession.
3. Odor or residual odor associated with prohibited substances or alcohol.
4. Statements made by an individual that may indicate that he/she uses prohibited substances or alcohol.
5. Red or droopy eyes, dilated or constricted pupils.
6. Slurred speech, stumbling, or hyperactivity.
7. Needle marks or other physical evidence that an individual has used a prohibited substance.
8. Unexplained disappearances from an Event.
9. Nose constantly runs, appears red, or persistent sniffling.
10. Unexplained tardiness, absences, or missed appointments;
11. Chronic forgetfulness or broken promises.
12. Involvement in an accident during an Event.
13. Inability to concentrate, remember, or maintain attention.
14. Mental confusion, paranoia, or expression of abnormal or threatening statements.

15.

Violent tendencies, loss of temper, or irritability.
16. Unexplained or excessive negligence or carelessness.
17. Extreme, unusual, or unexplained personality change, or unusual, irrational or erratic behavior.
18. Deteriorating personal hygiene or appearance.
19. Pattern of abnormal conduct.
20. Repeated failure to follow instructions or operating procedures.
21. Violation of USAC safety policies or failure to follow safe practices.
22. Display of any item that reflects that the individual may be in violation of this Policy.
23. Evidence that an individual has tampered with or not cooperated with a prior drug or alcohol test.
 
C. An arrest or conviction for driving while under the influence of alcohol or drugs, or a drug or alcohol related arrest or conviction.
   
D. Receipt of a report from a source deemed credible or reliable by USAC that a Competitor or Official is under the influence of drugs or alcohol on the day of an Event, or, at any time, that an individual is in violation of this Policy.
   
E. An examination or test, as provided by the USAC Rules, which shows evidence of use of a prohibited substance or alcohol abuse or of adulteration or manipulation of the specimen
   
F. Aroma of an alcoholic beverage or prohibited substance on or about the breath or body of a Competitor or Official consistent with use of a prohibited substance or alcohol.
   
G. Following an incident in which careless acts were observed in connection with an Event.
 
3. Testing: Scheduled and Random
At its sole discretion, USAC may require Competitors or Officials to submit to an annual and/or random testing for the use of a prohibited substance and/or alcohol. Selection of individuals for random testing shall be done by USAC, at its sole discretion.
 
4. Authorization for Testing and Release
If, upon request by USAC, a Competitor or Official refuses to promptly execute the authorization for testing and release form enclosed with this Policy and deliver it to USAC by the time designated by USAC for receipt, that Competitor or Official will not be issued an USAC Competitor's or Official's license and/or membership and, if already issued, the USAC license and/or membership will be suspended until the Competitor or Official executes the above mentioned authorization and release and delivers it USAC. If USAC directs a Competitor or Official to submit to a test to determine whether he/she is in violation of this Policy, that Competitor or Official must consent to and promptly and fully participate in and cooperate with the test in accordance with the instructions of USAC. If that Competitor or Official refuses to promptly consent and/or fully participate in and cooperate with such a test or tests within the time period designated by USAC, USAC may eject the Competitor or Official from the racing premises or take such other action as may be appropriate, and that Competitor or Official will also be subject to disciplinary action.
 
5. Screening
Annual random testing will be formal. While random or targeted testing may be formal, USAC may conduct random or targeted screening by USAC approved medical staff to determine if formal testing is appropriate.
 
6. Collection and Transport of Specimen(s) as to Formal Testing
USAC may designate specific USAC representatives or USAC may designate others to be in charge of collection of specimen(s) to be tested. Such designated individuals shall:
 
 
 
 
A. Ensure that the specimen(s) are from the Competitor or Official in question (including, where necessary, observation of the collection of the specimen(s)).
   
B. Ensure that the specimen(s) are collected within the time period designated. Normally, collection shall be made within one (1) hour or less of the notification of the Competitor or Official that testing will be conducted, unless a different time is designated by an Official based on the circumstances.
   
C. Ensure that the specimen(s) have not been adulterated or manipulated by promptly measuring the temperature of the specimen(s). Where results indicate that the sample is inappropriate for testing, USAC may require the Competitor or Official to provide additional specimen(s) as necessary.
   
D. Label, secure, and transport the specimen (s) to USAC's designated testing facility in such a manner as to ensure that the specimen(s) are not misplaced, tampered with, or relabeled.
   
E. Provide a form to be completed by the Competitor or Official in question that identifies all prescription and over-the-counter medications consumed by the Competitor or Official in the preceding three months.
 
7. Facility for Formal Testing
All testing will be performed at a facility or facilities selected by USAC at its sole discretion.
 
8. Technological Aspects of Testing
The USAC-designated testing facility will determine whether and in what amount a particular specimen tests positive with respect to a prohibited substance and/or alcohol, and whether the specimen has been adulterated or manipulated. The testing facility will transmit the results to USAC Director of Competition and to any designated third party medical review facility.
 
9. Procedures if a Test Shows the Presence of Prohibited Substances or Alcohol
A. With Respect to Prohibited Substances Other Than Alcohol:
 
1. Upon being notified that a Competitor or Official has tested "true positive" for a prohibited substance, USAC's Director of Competition or his/her designee may suspend that Competitor's or Official's USAC license and/or membership for an indefinite period and/or take such other disciplinary action deemed appropriate under the circumstances.
 
2. If that Competitor or Official wishes to return to racing or officiating during or after the suspension period, that Competitor or Official must submit to a re-test or re-tests. This will be done at a time and place and under conditions specified by USAC, at the Competitor's or Official's expense, which expense will include laboratory fees and all other direct and indirect costs incurred by USAC in connection with each test. If and when a Competitor's or Official's test shows no evidence of a prohibited substance, that Competitor or Official may be allowed to return to racing or officiating, but only if he/she is not otherwise ineligible. Furthermore, if the Competitor or Official does return to racing or officiating, he/she shall be subject to future tests for any substance, drug or alcohol, at such times and places as may be determined by USAC, at its sole discretion, and at the expense of the Competitor or Official.
 
B. With Respect to Alcohol:
1. Upon being notified that a Competitor or Official has been determined to have consumed alcohol in violation of this Policy, the USAC Director of Competition or his/her designee may suspend that Competitor's or Official's USAC license and/or membership for an indefinite period and/or take such other disciplinary action deemed appropriate under the circumstances.
 
2. If a Competitor or Official does return to racing or officiating during or after the suspension period, he/she shall be subject to future tests for any substance, drug or alcohol, at such times and places as may be determined by USAC, at its sole discretion, and at the expense of the Competitor or Official.
 
C. Testing Results
USAC may publish the results of any test or tests conducted pursuant to this Policy and the circumstances giving rise to such test to such third parties as USAC, in its sole discretion, deems reasonable under the circumstances. The Competitor or Official shall have no claim or cause of action of any kind against USAC or any director, officer, employee or agent of USAC with respect to such publication. It is the intent of USAC, and USAC will endeavor to, treat the results of any test or tests as confidential as warranted by the circumstances.
 
10. Falsification or Withholding Information
Any Competitor or Official who attempts to or does falsify, alter, or otherwise tamper with, adulterate or manipulate any specimen or any aspect of a test performed under this Policy will be subject to disciplinary action that USAC in its sole discretion deems appropriate. A specimen that is identified as having been adulterated or manipulated shall be treated in the same manner as a "true positive" test result for a prohibited substance other than alcohol, with all of the consequences of such a positive test, including those provided in Paragraph 9.A. 1. and 2, above.
 
11. Disciplinary Action for Prohibited Acts Where There is No Evidence of or Testing for Prohibited Substances or Alcohol
With respect to any prohibited act described herein, if USAC determines that a Competitor or Official has engaged in any such prohibited act, USAC may eject the Competitor or Official from the premises or take such other action as deemed appropriate by USAC in its sole discretion, and that Competitor or Official shall also be subject to disciplinary action that USAC in its sole discretion deems appropriate.
 
12. Treatment for Drugs/Alcohol:
USAC does not provide drug or alcohol rehabilitation programs. However, USAC strongly encourages self-help and treatment for those who may have a drug or alcohol abuse problem. Many worthy programs, both public and private, are available for the treatment of drug and alcohol abuse. USAC will continue its efforts to support a drug-free America and a society in which alcohol is not abused.
 
13. Applicability of the USAC Rules
This Policy, as it may be amended from time to time, is a supplement to the provisions of the USAC Rules, and will be interpreted and applied by USAC. This Policy is binding upon all USAC members in the same manner and to the same extent as are the provisions of the USAC Rules.
 
 
 
 
 
 
 
 
 
 
 
 
 
Listing of Prohibited Substances:
 
Amphetamines Ephedrine Class Narcotics Benzodiazepines Barbiturates
Amphetamine Ephedrine Alfentanil Alprazolam Amobarbital
Methamphetamine Psuedoephedrine Codeine Diazepam Butabarbital
MDMA Phenylpropanolamine Dihydrocodeine Lorazepam Pentobarbital
MDEA Fentanyl Oxazepam Phenobarbital
MDA Hydromorphone Temazepam Secobarbital
PMA Hydrocodone  
  Meperidine  
Other: Methadone Specimen Validity:
Marijuana Morphine Nitrites
Cocaine/Crack Oxycodone Chromates
Meprobamate/Carisoprodol Propoxyphene Specific Gravity
Methylphenidate Sufentanil  
 
Zolpidem  
 
USAC Substance abuse policy authorization for testing and release
I have read the United States Auto Club (USAC) Substance Abuse Policy. I hereby give my consent to USAC and its designated agents to collect blood, urine, saliva, hair, and breath specimens from me; and to screen and/or test those specimens for the presence of alcohol and/or any prohibited substance under USAC's Substance Abuse Policy; and to conduct such other tests as USAC deems necessary from time to time to determine my fitness to participate in or at an Event, all as set forth in the USAC Substance Abuse Policy as it may be amended from time to time. In addition, I give my permission to any doctor, nurse, technician, laboratory, or health facility which administers drug or alcohol tests or screens to release the results of any tests of examinations to USAC.
 
I recognize that the USAC Substance Abuse Policy has been adopted and is administered by USAC to promote the integrity of USAC-sanctioned racing. Accordingly, I ALSO HEREBY RELEASE, DISCHARGE, COVENANT NOT TO SUE AND AGREE TO HOLD HARMLESS USAC, its officers, employees, representatives, agents, and testing facilities, as well as any individual or company in any way affiliated with USAC and any other persons or entities against whom I might have a claim, from and/or for claims, damages, losses, or expenses of any kind, whether caused by negligence or otherwise, arising out of the implementation of the USAC Substance Abuse Policy, or any act or omission in connection therewith, including and without limitation the testing of specimens and the publication of the test results and circumstances giving rise to such test or tests to any third party or parties by USAC or said drug testing facilities, as well as the officers, employees, and agents of each of them, or any other persons or entities.
 
 
I have read and agree to the Annual Release and Waiver of Liability.
 
Applications must be filled out completely and accompanied by the required fees. Applicants must provide an authorized signature below agreeing to all terms of the license(s) for license to be processed.
Applicants Name Printed: ___________________________________________________________________________________________
Signature: _______________________________________________________________________________________________________
Date: __________________________________________________________________________________________________________
Payment Information:
Amount Due: ____________________________________________________________________________________________________
Check#_________________________________________________________________________________________________________
Credit Card#:_____________________________________________________________________________________________________
Expiration Date: ___________________________________________________________________________________________________
 
Office Use Only    
Paid by: Check # _____________ Cash _____________ Credit Card (Last 4#'s) _____________
Amount Paid: _____________    
Date Paid: _____________