Date of Birth:(00-00-0000)         Age:

Rider Full Name:
              Address:
                       City: State: Zip Code:

Phone: CELL HOME WORK (123-456-7890)

eMail:

Do you have Medical Insurance? Yes No

Company Name: Policy Number:

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REQUIREMENTS:
(You must select one)

I have possessed a race license from a recognized race organization within the past 3 years.
                                        I was last registered as a Expert Amateur racer

I am applying for a race license based upon training at a approved road racing school that I have completed within the previous 12 months as stated below:
         Name of School: Date and Track

All the supporting documentation required
is to be attached to your application before it can become valid and a MCRA Challenge Series race license issued.

Mail it to:
MCRA Competition License
PO Box 16591
St. Louis, MO  63105
or bring to the registration booth at the track
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BIKE NUMBER REQUESTS:
(we will do our best to give you your selected number, however in the case of duplicates we may assign you a competition number)

Competition Race Number: 1st choice 2nd 3rd 4th (3 digit numbers)

Number Plate Background Color: Yellow (amateur) White (expert)

READ THIS RELEASE

RELEASE: I, hereby release, and agree to hold the MCRA (Midwest Cafe Racing Association) , the promoters, the owners and lessees of the premises, the participants, and the officers, directors, officials, representatives, agents and employees of all of them, of and from all liability, loss, claims and demands arising in connection with this event, and whether arising while engaged in competition or in the practice or preparation therefore, or while upon, entering or departing said premises, from any cause whatsoever, I know the risks and danger to myself and property while upon said premises or while participating or assisting in this event, so voluntarily and in reliance, upon my own judgment and ability, I hereby assume all risk for loss, damage or injury (including death, loss of limbs and permanent disablement) to myself and my property from any cause whatsoever.
AGREEMENT: By my submission and signature, I hereby agree to the terms of the above release and further agree to abide by the rules and regulations set forth by the MCRA and any special regulations in all participation with the license. I understand that the issuance of a MCRA Challenge Series Race License will only permit racing in the MCRA Challenge Series. I certify that the above information regarding my age, identity and any other information submitted is true and freely given for the purpose of obtaining a MCRA Challenge Series Race License.

I have read and agree to the above Release and Agreement.

I disagree with the release.

NOTE:
After you click "Submit Your Application",
print the following page for your records.