Kankakee County Speedway
213 W 4000 S / Kankakee, IL 60914 / (815) 935-9000
2011 DRIVERS REGISTRATION FORM
UMP LATE MODEL / UMP MODIFIED / UMP STOCK CAR / I-MOD / UMP SPORT COMPACT
CLASS (CIRCLE ONE): LM 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 2011 ROY Candidate? Yes or No
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
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!
