Region9 ENTRY BLANK

          

  Event Location for Year 2024 Race: *

Registration Type:  *

Required *    A Separate Entry is Required for Each Class 

Driver

 Owner Rider/Co-Driver

Name*

Name * Name
Add.* Add*

Add.

City  *

City * City 

State*    Zip*

State *      Zip*

State     Zip

Region*             Age *

Region *            Age *

Region           Age

Club Affiliation * Club Affiliation* Club Affiliation

APBA Member No.  *

APBA Member No. * APBA Member No. 
IN CASE OF EMERGENCY CONTACT:  *

AT RACE SITE? * If No where?  PHONE #   *

Boat/Driver qualifications for Kilos or Championship Races (As Required by Division Rules)
Date Location Other
Helmet Mfg. * Helmet Type: *

    Allergy?: *

 Allergy Details:
Life Jacket Mfg.  *   Jacket Type:  *

CATEGORY:*    

Class*

 Boat Number* Boat Name Hull Make Motor Make* Cu. In. Disp.*

      This Entry Blank MUST be filled in with ALL DETAILS and filed with the local Race Committee in accordance with APBA General Racing Rules 3, 4, and 5. Owners and Drivers must report immediately to Registration Headquarters upon arrival at race, present current membership card and have entry checked. Drivers failing to do so and starting in race will not be scored. Entry will not be accepted unless properly signed.

AGREEMENT OF RELEASE
     I represent by my signature below that my Agreement of Release is on file with my current membership, and my membership card number is as shown above.
     I further represent, if I do not possess a current membership card, that I have signed the current Agreement of Release attached with my membership application previously mailed to National Headquarters, or submitted to Registration Officials at the above regatta.
     In consideration of their promotional efforts on behalf of the sport, I hereby assign all commercial communication and broadcast rights to the American Power Boat Association and do declare them as my lawful agents and representatives regarding such rights.
    I, the undersigned member participating in events sanctioned by APBA, agree that APBA and its assigns may use my name and picture and pictures of my race boat, or any of them, in any way, medium, or, material for promoting, advertising, recording, reporting any APBA sanctioned events before, during and after such event and do hereby relinquish all rights hereto for these purposes.
Signed (Driver):                                                                               (LS.) 

Home Phone*

Signed Owner):                                                                                   (LS.)

 Home Phone*

Signed (Rider/Co-Driver):                                                                      (LS.)
Signed (Parent/Guardian for (Name):                                                        

If under 18:                                                                        (LS)
MUST BE SIGNED AT RACE OR MAILED WITH ALL SIGNATURES

Form 583-Rev. 7/99
E-mail address:*

This form MUST be submitted by the date required on the official Circular.  The form is not fully submitted until a personal reply confirmation is received from the Chief Scorer

(usually in 2-3 days)

Notes:

----No Open Events----