Nor-Cal Dwarf Car Association
6095 Rainier Avenue
Rocklin, CA 95677
(209)836-4722 (Jan)
2008 Membership Application
CAR OWNER:
ADDRESS
CITY
STATE:
ZIP
PHONE
#: .CELL#
EMAIL ADDRESS
SOC. SEC#: _______________________
(of payee – please indicate if payee other than “driver”)
DRIVER'S NAME (if different from owner)
DRIVER'S SPOUSE NAME
DRIVER
BIRTHDATE: SPOUSE
BIRTHDATE
CAR OWNERS BIRTHDATE (if different from
driver or spouse)
CAR YEAR/BODY STYLE:
CAR
# 1ST CHOICE: 2NDCHOICE 3RD CHOICE
SPONSOR'S:
_______________________________________________________________________
_______________________________________________________________________
PREVIOUS EXPERIENCE_______________________________________________________________________
_______________________________________________________________________
ANNUAL DUES: $100.00 (Includes owner's card and driver's card) each. Membership
expires 11/31.
I hereby apply for membership in the
N.C.D.C.A.
Liability release: In consideration of the
acceptance of the right to participate, entrants, participants, and
spectator's, by the execution of this form, release, and discharge the NCDCA
and their officer's director's, employees, agents, representatives, members,
and servants and anyone else connected with the management for this event of
and from any and all injuries and damages, whether the same is known or
unknown, inquires, losses, judgements, and or claims from any causes or damages
whatsoever that may be suffered by an entrant to his person or property.
Further, each entrant, participant, or spectator expressly agrees to indemnify
and hold harmless all of the foregoing entities, firms, persons, and bodies of
and from any and all liability occasioned or resulting from the conduct of
entrants or any and all liability occasioned or resulting from the conduct of
entrants or any participants assisting or cooperating with entrant or any
participants assisiting or cooperating with entrant and under the direction and
control of entrant.
SIGNATURE OF
APPLICANT: DATE: