MCRA RACE LICENSE APPLICATION

Do Not fill this out if you have not made a payment.
Application forms submitted without a payment will not be processed.
Contact Information (Required)

First Name:
Last Name:
Spouses Name (if applicable):
Address:
City:
State/Providence:
Country:
Zip/Postal Code:
Contact Email Address:
Phone Number:

Do you have medical insurance?  YES   NO  If yes, please supply info below:
                   Company Name:   Policy Number:

READ THIS RELEASE

RELEASE AND ASSUMPTION OF RISK: I, hereby release, and agree to hold harmless the Midwest Cafe Racing Association (MCRA), owners, the participants, the officers, directors, officials, representatives, agents or employees from all liability, loss, claims and demands that may accrue from any loss, damage or injury (including death, loss of limbs and permanent disablement) to my persons or property, in any way resulting from, or arising in connection with this event, and whether arising while engaged in competition or in practice or preparation therefore, or while upon, entering or departing from said premises, from any cause whatsoever, I know the risk 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 thereby 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 submitting this form, I hereby agree to the terms of the above release  and further agree to abide by the current Road Race Rules and Regulations and any Special Regulations in all participation with this license. I hereby agree to allow my likeness to be used for promotional purposes by the MCRA and their affiliates without any further compensation to myself. I certify that the above information regarding my identity and experience is true and freely given for the purpose of obtaining a race license.