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!