2013 driver registration form

DRIVER REGISTRATION #_________________________ 2013 CANEY VALLEY SPEEWAY / DRIVER REGISTRATION PLEASE PRINT LEGIBLY NUMBER REGISTRATION 1st choice__________ 2nd choice__________ Please Circle you car class: B Modified Micro Late Model Pure Stock Factory Stock Jacket Size____________ Driver’s Name___________________________________ Age_________ Social Security Number:_________________________________________ Home Phone:_____________________ Cell Phone:___________________ E-mail:_______________________________________________________ Driver’s Address:_______________________________________________ City:_____________________State:_______________Zip Code:_________ CAR INFORMATION: Car Owner:_________________________Phone:_____________________ Social Security Number__________________________________________ EMERGENCY INFORMATION: Contacts:____________________________Phone:____________________ Medical Conditions or Allergies:___________________________________ Competitor’s Signature__________________________________________ CANEY VALLEY SPEEDWAY FEE $30.00 Make checks payable to:Kerry Gorby Mail form and money to:1520 CR 2400 Havana, KS 67347