NAME_______________________________________                   PHONE____________________________

STREET________________________________________________________________________________

CITY, STATE______________________________________________                  ZIP____________________

EMAIL:                                                                                               

*BIKE BRAND_________________              *BIKE SIZE_________________                   *BIKE #___________

Engine	Skill level	Engine	Skill level	Engine	Skill level
0 – 230cc	A	250cc – Open	A	30+, 40+, 50+, 60+	All levels
0 – 230cc	B	250cc – Open	B

I hereby agree to conform and comply with the rules governing this event in connection with competition rules.  I further agree to hold  blameless the Event Committee, the Director of Events, the Promoters, Owners of the property, for any loss or injury to myself or  property in which I may become involved by reason  of participation in  this event at Southern Raceway in Bainbridge, Georgia.

Name of Racer_______________________________________________  Date________________________

(Parent or Legal Guardian must Co-Sign if under 18)

Signature of Parent/Legal Guardian___________________________________________________________

Signature of Racer over 18__________________________________________________________________

NAME_______________________________________                   PHONE____________________________

STREET________________________________________________________________________________

CITY, STATE______________________________________________                  ZIP____________________

EMAIL:                                                                                               

*BIKE BRAND_________________              *BIKE SIZE_________________                   *BIKE #___________

Engine	Skill level	Engine	Skill level	Engine	Skill level
0 – 230cc	A	250cc – Open	A	30+, 40+, 50+, 60+	All levels
0 – 230cc	B	250cc – Open	B

I hereby agree to conform and comply with the rules governing this event in connection with competition rules.  I further agree to hold  blameless the Event Committee, the Director of Events, the Promoters, Owners of the property, for any loss or injury to myself or  property in which I may become involved by reason  of participation in  this event at Southern Raceway in Bainbridge, Georgia.

Name of Racer_______________________________________________  Date________________________

(Parent or Legal Guardian must Co-Sign if under 18)

Signature of Parent/Legal Guardian___________________________________________________________

Signature of Racer over 18__________________________________________________________________