APPLICATION FOR DISTRICT 34 SPORTS COMMITTEE CARD

Name

Parents Name (minors only)

Date of Birth

         Age

Street Address1

Street Address2

City

State

         Zip Code

Telephone

  (include area code)

Email Address

  (if applicable)

AMA#

  (if applicable)

Club

(if applicable)

Preference of riding #

Select one of the following that best reflects your present D34SC Status:

PeeWee      Jr Mini       Senior Mini      Novice      Amateur      Expert
                    Quad Expert       Quad Amateur    Quad Novice   Women

**** PAGE 1 OF 2 ****

IF ONLY THIS PAGE PRINTED YOUR PRINTER IS NOT WORKING PROPERLY

DISTRICT 34 Application continued ....

In consideration of being granted a D34 card and in consideration of being permitted to enter competition events sanctioned by  the District 34  Sports Committee herein known as D34SC, for myself, my heirs, personal representatives and assigns, herby release, discharge, and agree to hold harmless and indemnify the D34SC, promoters presenting sanctioned events, the owners and lessees of premises on which sanctioned events take place, the participants in sanctioned events, the owners, sponsors and manufacturers of all racing equipment upon the premises, and the officers , directors, officials, representatives, agents and employees of all of them, of and from all liability, loss, claims, demands and possible causes of action 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 other persons.  I know the risk and danger to myself and property while upon said premises or while participating or assisting in a sanctioned event, and I do so 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 for loss, damage or injury (including death) to myself and my property from any cause whatsoever and whether or not attributable to the negligence of others.

MEDICAL INSURANCE IS THE RESPONSIBILITY OF EACH RIDER

Parents or guardian of any rider under the age of eighteen may withdraw their permission signed at the bottom of this form at any time upon returning to the D34SC by return registered mail, the D34SC card issued to said minor and upon notification of   the withdrawal of such permission.  I understand that a D34SC card is subject to D34SC and AMA rules for competition.

Have your read this application?       (please type "YES" or "NO")

Now please PRINT this entire form AFTER you "TYPED IN" all of the above information on your computer.  Now remove the document from your printer and sign in ink below:

Rider Signature:   ------------------------------------------------------------      Date: ---------------------------------

NOTICE: IF UNDER 18 YEARS OF AGE, this application must bear the notarized signature of parent or guardian which shall acknowledge a waiver and release of any and all claims such parent or guardian may have.

Parent/Guardian Signature:   ----------------------------------------------------------------------------     

Subscribed and Sworn to before me this --------------------  day of --------------------------,    ---------------

Notary Public: -------------------------------------------------------------------------------------------------------------- 

**** PAGE 2 OF 2 **** 

 INSTRUCTIONS:

#1. Enclose the appropriate fee.  Do not send cash. The fee must be sent in the form of a money order or certified check.  Very important or your application will be returned.  And absolutely no personal checks.
$20.00 for a regular seasonal membership (if you do this at the track on race day it will cost $25.00)
$10.00 for an associate membership (an "associate membership" has no racing privileges / just mailings)

#2. You must  prove your age by sending a copy of your driver's license or birth certificate.  And if you are under 18 years of age the application must be notarized.

#3.  Mail the signed form (BOTH PAGES THAT YOU SEE ABOVE !!!!)
                 and your certified check or money order to =======>

District 34 Sports Committee
c/o Jeannine Price
21 Holiday Mtn Rd.
Monticello , NY  12701

#4.  Further questions?  Contact Jeannine Price at 845-796-2515

BACK TO D34 PAGE