For Office Use

Office Use Only

Track Membership $25

Car # ________
IMCA Modified, IMCA Stock Car, Hobby Stock
IMCA Sport Modified, 4 cyl. Wild Thing Class ________
Reserved Parking Available - $50
PO Box 226, Denmark, IA 52624
(319) 528-4301 * Fax (319) 528- www.leecountyspeedway.com Pkg # ________
4302
OFFICE USE ONLY

Rcd. By _________ Date Paid _________ Amount _________ Cash CC Check # ______ IMCA 
This form MUST be completed, signed and all fees paid in order to receive prize money. PLEASE PRINT CLEARLY!

DRIVER’S Name ________________________________________________ Car# _________________

DRIVER’S Social Security # ______________________________________ Class _________________

DRIVER’S Address _____________________________________________________________________

City _______________________________________ State _________________ Zip Code ______________

Phone # ____________________________ e-mail address ______________________________________

Cell Phone # _________________________  Check this box to receive Text Message Updates (such as Rain outs)


PRIZE MONEY AUTHORIZATION – If other than driver

Person or Business that Federal 1099 should go to if other than above – If same as driver you may leave blank.
Required by Federal Government to avoid a 28% withholding of prize money.

SS# or Federal ID # _________________________________________________ (must match check’s payable)

Make Checks Payable to ____________________________________________________________

Address _______________________________________________________________________________

City ____________________________________ State _________________ Zip Code _________________

Phone # ____________________________ e-mail address ______________________________________

Cell Phone # _________________________  Check this box to receive Text Message Updates (such as Rain outs)


AGREEMENT
CONTRACT: I am an independent contractor assuming all responsibility for money received as a result of my activities
including, without eliminating, income tax, FICA, workman’s compensation and withholding taxes. I am not an employee,
servant or agent of Lee County Speedway, Inc.
BENEFITS: I agree that myself, executors, and assigns will be entitled only to the benefits of the Competitor Accident
Policy procured by Lee County Speedway, Inc. for accidental injuries which are the result of external, violent, and visible
means sustained in Lee County Speedway, Inc. events. The foregoing shall constitute the limit of liability of Lee County
Speedway, Inc. for such injuries occurring to me in any Lee County Speedway, Inc. event provided proper notification is
given.
COMPLIANCE: The undersigned agrees to abide by all rules and regulations of Lee County Speedway, Inc. now published
or hereinafter modified. In consideration of the acceptance by Lee County Speedway, Inc. of this agreement the
undersigned recognizes his obligation to the public and Lee County Speedway, Inc. which posts the prize money and
conducts the events, and agrees to compete in all events when qualified if humanly possible.
BREACH AND DAMAGE: In the event the undersigned breaches this agreement he shall be liable for actual liquidated
damages sustained by Lee County Speedway, Inc.
OWNERSHIP: If owner of a registered car, I certify I have good and marketable title to said vehicle or any part thereof in
the event the same is claimed pursuant the rules.
ADVERTISING RELEASE: The undersigned consents to the use of his name, pictures of himself, and his car for publicity,
and relinquishes any rights to photos taken in connection with events and consents to the publication or sale of such
photos as Lee County Speedway, Inc. so desires.
ARBITRATION: Any controversy or claim arising out of or relating to this agreement including any alleged breach, shall be
settled in accordance with the rules and regulations of the Lee County Speedway, Inc. and the undersigned agrees to
accept the decision rendered by this process.
I HAVE READ AND FULLY UNDERSTAND THIS AGREEMENT. I AGREE TO ABIDE BY ALL TERMS OF
THIS AGREEMENT AND THE REQUIREMENTS OF THE RULES OF THE LEE COUNTY SPEEDWAY, INC.