California Sports Car Club
Entry Form

2005 Entry Form

Event: 
Cal Club Double Regional GT Blast/Pacific Formula 2000	Date:
Sept 3-4, 2005	Late Entry Deadline:
 August 27, 2005
	Sanction #s: 

05-RS-126-S 
05-RS-127-S 
	Track / Location: 
Buttonwillow Raceway Park	
 National      Regional Saturday Only      Regional  Sunday Only      Regional Saturday and Sunday 		
Log Book ID
	Make
	Model
	Year
	Color
	Class
	Car Number Choices	
						1st  	2nd  	3rd  	
Transponder # - Required  	E-mail
	Registrar Use
Only	
Driver's Name (Please print legibly)
	Daytime Phone
	Run Group	
Address
	Evening
	Car #	
City
	State
	Zip Code
	Fax
	Class	
Membership Number
	Expiration Date
	License Grade
 Reg    Nat    Dual    FIA    Novice 	Member/License OK	
Region of Record
	Cal Club Associate or Lifetime Member?       Yes   No	If Renting, From Whom?
	Tech Card Given?	
Entrant ( if different than driver )
Name
Address
City, State, Zip	Entrant Member #  AND Expiration Date	Waiver Signed?

		Payment Type:

 Cash
 Check
 Credit Card

Total Paid

$___________

Registrar Initials	
Sponsor(s) 		
In Emergency, notify?
	Phone
	At Track?
Yes      No		
Circle Payment Type, Payable at Registration (If paying with a credit card, bring card to registration.)                               Check	    Visa	          MasterCard 	     Cash
Card #                                                                                                                 Expiration Date: 	
ADD WORKER DONATION OF

$____________		

It is agreed that the entry, if accepted, shall be a contract between the Driver/Entrant & the SCCA/California Sports Car Club Region under which the above car & driver will take part in the competition described, unless prevented by force beyond control of the Driver/Entrant.  This event will be conducted under the SCCA 2005 General Competition Rules & California Sports Car Club 2005 Supplementary Regulations and the Entrant & Driver agree to abide by these rules. All participants must sign a release agreement at Registration before entering the track facility.	

Driver Signature _____________________________________    Entrant Signature  ________________________________________	
	Entry Fees:	SRF / FSCCA / SCCASR Fees:	Late Fees:	Total Fees:	PLEASE SEND ENTRY TO:

Cal Club Registrar
California Sports Car Club
18202 Cal Club Drive
Buttonwillow, CA  93206
Phone:  661.764.5945
Fax:      661.764.5944
E-Mail: calclubgm@aol.com

 Single Regional
Double Regional
Worker Donation	$210
$300

	$ 10
$ 20
	$ 40
$ 40

     TOTAL	$ ___________________
$ ___________________
$ ___________________
$ ___________________
$ ___________________		

	

California Sports Car Club
2005 Medical Form

2005 Entry Form

Driver Medical Information – Driver must complete ALL questions

Event: 
Cal Club Double Regional GT Blast/Pacific Formula 2000	Date:
Sept 3-4, 2005	Sanction #s: 
05-RS-126-S 
05-RS-127-S 
	Track / Location: 
Buttonwillow Raceway Park	

Please write legibly

Driver's Name 
	Date of Birth 
	Blood Type 
	Date of Last Tetanus
	Registrar Use Only	
Driver's Address, City, State & Zip
	Daytime Phone
	Run Group	
	Evening
	Car #	
Drug Allergies or Medical Conditions
	Illness/Injury from Past 12 months
	Class	
Current Medications
	
Physician's Name
	Address   	Phone
	
Yes or No:	Contacts  
Hemophiliac  	Dentures  
Heart Problems  	Asthmatic  
Allergies  	Diabetic   
Organ Donor  	Epileptic  	
In Emergency Notify?
	Phone
	At Track:
Yes       No	Religious Preference

I certify that the medical information provided by me is true and accurate.

Driver’s Signature: __________________________________________________      Date: _____________________

Please NOTE:  All fields must be filled out completely for an entry to be accepted