OFFICIAL ENROLLMENT FORM

Name:________________________________________________

Mailing Address:__________________________________________________

City:_______________________________ State:___________ Zip: _________

Age: _________________ Team Duties_____________________

Type of Competing Vehicle: AMRA OPEN WHEEL MODIFIED

Coverages: $50,000 EXCESS MEDICAL

Participant signature: __________________________________ Date:______________

AMRA Office signature: ________________________________ Date:______________

Driver Cost: $40 per year
*coverage is excess over track's existing Medical Program $15,000 deductible

Please return the completed and signed form, with the appropriate fee to:

American Motor Racing Association / Rt. 2, Box 590 / Leon, WV 25123
(304) 895-3602