Kankakee County Speedway Driver Registration Form        K3#                  UMP#                       

 213 W 4000 S / Kankakee, IL 60901 / (815) 935-9000

 2017 DRIVERS REGISTRATION FORM

 UMP PRO LATE MODEL / UMP MODIFIED / UMP STOCK CAR / I-MOD / UMP SPORT COMPACT     

 CLASS (CIRCLE ONE)  PLM  MO  SS  IM  SC    CAR # ____________

 Driver’s Name: ________________________________________________________________________

 Street Address: ________________________________________________________________________

 City: ____________________________ State: ___________________ Zip Code: __________________

 E-Mail Address: _______________________________________________________________________

 Home Phone: (_______) ______________________ Work Phone: (_______) ____________________

 Are you at least 12 years old?   Yes  or  No           Date of Birth:                                  2017 ROY Candidate?   Yes  or  No

* UMP MEMBERSHIP IS MANDATORY FOR ANY DRIVER WITH MORE THAN THREE STARTS



 SOCIAL SECURITY OR TAX I.D. NUMBER OF PERSON OR ENTITY TO RECEIVE 1099 INFORMATION

 Name or Entity: _______________________________________________________________________

 Address: _____________________________________________________________________________

 City: ______________________________ State: __________________ Zip Code: _________________

 Phone: (________) __________________ SSN or Tax I.D. No.: _________________________________

 Signature: ____________________________________________ (Title if Corp) ___________________



 DRIVER / CAR INFORMATION

 Vehicle Make: ________________ Yr.: _________ Model: __________________ Color: ______________

 Sponsors: _____________________________________________________________________________

 Years Racing: ________________ Championships: ____________________________________________



 OPTIONAL INFORMATION  (for track announcer and public relations purposes)

 Occupation: ___________________________________________________________________________

 Hobbies: ______________________________________________________________________________

 Married: Yes or No      Spouse’s Name:
 __________________________________________

 DISCLAIMER: I understand that my signature here along with the proper registration fee makes me a member of the Kankakee County

 Speedway. I agree to abide by the racing rule book of Kankakee County Speedway and it’s interpretation by officials. I hereby give my

 permission to use photographs of myself and/or race car as part of their racing publicity promotions. I agree not to hold Kankakee County

 Speedway responsible for disqualification or damage to either car or driver and I agree that I consider the track is in safe racing

 condition when I take part in any racing activity.


 SIGNATURE: _________________________________________________ DATE: _________________

 NOTE: ANY PAYOFF NOT PICKED UP ON RACE NIGHT  CAN BE PICKED UP AT THE NEXT RACE!