M.S.C. Member's Medical Form Medical information
Last Name _____________________________ First Name ___________________________
Health Insurance____________________________________________
Health Insurance Group Number ______________________________ Subscriber Number _________________________
Dental Insurance ____________________________________________
Dental Insurance Group Number ______________________________ Subscriber Number _________________________
Date of Birth ________________________________
Emergency Contact Name: _______________________________________________________
Emergency Contact CELL Phone: _______________________ Landline: ______________
Emergency Contact Address: ___________________________________ City: _________
Medications:
Allergies:
Other Medical Issues:
I. for myself, my heirs, personal representatives and assigns, hereby release, discharge, and agree to hold harmless and indemnity the M.S.C., the owners and lessees of premises on which these events take place, the participants In these events, the owners, sponsors and manufacturers of all racing equipment upon the premises, and the officers, directors, officials, representatives, agents and employees of all of them, of and from all liability, loss, claims, demands and possible causes of action that may otherwise accrue from any loss, damage or injury (including death) to my person or property, in anyway resulting from, or arising in connection with, or related to M.S.C. events, and whether arising while engaged in competition from any cause whatsoever including without limitation the failure of anyone to enforce the rules and regulations. I know the risk and danger to myself, or while participating or assisting in M.S.C. events. and I do so voluntarily and in reliance, not upon the property, equipment, facilities and existing conditions furnished by others, but upon my own judgment and ability, and 1 thereby assume ail risk for loss, damage or injury (including death) to myself and my property from any cause whatsoever and whether or not attributable to the negligence of others.
I hereby declare that to the best of my knowledge and believe, I upon oath, state that ail statements set forth on this form are true and correct.
Signature ________________________________________ Date ____________________
Minor's Release: Any person under eighteen (18) years of age must have a Minor's
Release form signed by parent or legal guardian before they will be allowed to
participate in any racing event.