Lane Automotive 50 Race of Champions Entry Form

*Please mail by October 4, 2014 - Assists parking plan of Semi / Toter Haulers

Entry Fee - $100
Includes: 2-Day driver pit pass & Transponder rental both days
Online payments at:

Portion below must be fully completed and mailed with entry fee to:
Plymouth Speedway (Attn: ROC)
14330 N 300 W
Silver Lake, IN 46982

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In consideration of Plymouth Speedway's approval of this entry application and for the opportunity to participate in the event, each of the undersigned agrees as follows:
1. ACKNOWLEDGEMENT AND AGREEMENT TO ABIDE BY RULES: I acknowledge that I have read and understand all terms and provisions in the Official Entry Form and in all Special Rules published by Plymouth Speedway for this Event, and that I will abide by all such terms and provisions, as they may be amended from time to time, and by all decisions by Plymouth Speedway or its Officials
interpreting and applying them.
2. ADVERTISING AND PROMOTION RELEASE. Plymouth Speedway, its duly authorized agents and assigns, may use my name, likeness and performance, including photographs, images and sounds of me and/or any vehicle(s) with respect to which I compete in Plymouth Speedway-promoted events, in any way, medium or material (including but not limited to broadcasts by and through television,
cable television, radio, pay-per-view, closed circuit television, satellite signal, digital signal, film productions, audiotape productions, transmissions over the internet, public and private online services authorized by Plymouth Speedway, and the like) for promoting, advertising, or reporting any Plymouth Speedway-promoted event before, during and after such event, and I do hereby relinquish to Plymouth Speedway all
rights thereto for such purposes: provided, however, that, I shall retain the exclusive use of my name, picture and likeness in connection with product endorsements and the sale of products, services, concessions and merchandise.
3. PERSONAL INJURY AND PROPERTY DAMAGE RELEASE. I hereby release and waive any and all claims pursuant to the RELEASE AND WAIVER OF LIABILITY AND INDEMNITY AGREEMENT as posted and signed at Registration.
4. ENTRANT'S "GOOD FAITH TO THE PUBLIC PLEDGE." In recognition of the support of the racing fans, and the effort and monies expended by the sponsors and Plymouth Speedway in connection with the Event, I agree to use my best efforts to compete in the Event, including related practice and qualifying activity, and I will not withdraw from competition without the consent of the
Plymouth Speedway Promoter or his designee. If the Driver for any reason is unable to compete, the Car Owner will use its best efforts to identify and use a substitute driver in order to compete.
PAYMENT INFORMATION: CHECK# ________________________________________________ AMOUNT $______________________
ONLINE PAYMENT ORDER #: ___________________________________________________________________________________
DRIVER (Print)___________________________________________________________________ AGE ________________________
  (Anyone Under 18 Will Require Parental Consent.)
SSN or Fed. Tax ID #______________________________________________________________
Registration for Group "A" 2014 Track Champion/Series Point Champion
Track/Series: __________________________________________________________
  (Note you must provide proof of Championship to enter)
STREET ___________________________________________________________ CITY_____________________________________
STATE ___________________________________ ZIP ______________ PHONE (_____) ___________________________________
DRIVER'S SIGNATURE __________________________________________________________________ DATE___________________
I acknowledge that I have fully read and understand the rules and regulations governing the mechanical and technical requirements for the event. I assume responsibility for the legality and safety of my car and accept all penalties issued by the Race Director and/or officials. I acknowledge that I am responsible for the actions of my Car Owner, Crew Chief and Pit Crew
and that they must abide by all PLYMOUTH SPEEDWAY rules, regulations and decisions as well as the stipulations announced by the Race Director and/or officials. I acknowledge that my event finishing position and prize money may be subject to penalty for the actions of myself, my Car Owner, Crew Chief and Pit Crew.
CAR#: ______________ 2nd Choice: ____________________ HOME TRACK: _______________________________________________________
CHASSIS: ____________________________ MAKE: _______________________ COLOR(S): ___________________________________________
CAR SPONSORS: ________________________________________________________________________________________________________



EMAIL: _______________________________________________________________________ HAULER (H x L): ___________________________
TRANSPONDER#: ___________________________________________________
EMERGENCY CONTACT _______________________________________________________ Phone: ( ______ ) ______________________________
RELATIONSHIP _______________________________________________________________
CAR OWNER (Print): _________________________________________________________________ SSN or Fed. Tax ID #: ___________________
STREET: _____________________________________________________________________ CITY: ____________________________________
STATE: ________________________________ ZIP: _____________________ PHONE: ( ______ ) ______________________________________
OWNER'S SIGNATURE: ________________________________________________________________ DATE: _______________________________