2013 4 Wheel Parts Last Chance Qualifier
Transcription
2013 4 Wheel Parts Last Chance Qualifier
CAR NUMBER DRIVER OF RECORD ALL RACE PARTICIPANTS MUST COMPLETE & SIGN ADDITIONAL PAGES OF THIS FORM INCOMPLETE ENTRY FORMS WILL BE DENIED; RACE TEAM NUMBERS ARE ISSUED BASED ON A SENIORITY ONLY BASIS. NO LETTERS WILL BE ACCEPTED (This entry form does not guarantee entry into the 2013 Griffin King of the Hammers. ) All entries must be complete including additional requested information. Entry into the GRIFFIN King of the Hammers is limited to pre qualified drivers only. 10 Teams will advance. This is a time sensitive document. Entry is limited to 60 drivers Make checks payable to: Hammerking Productions Inc 1040 Mount Vernon Ave. Suite G-309 Colton, California 92324-4228 Entry fee is $400 if payment received 9/15-10/15, $450 payment received 10/16-11/15, $600 after 11/16. Advancing teams will be able to credit $200 towards the 2013 King of the Hammers race entry fee. Cash only. Payable following the announcement of LCQ qualified teams. The 4Wheel Parts Last Chance Qualifying guarantees at least 10 teams will advance to the 2013 Griffin King of The Hammers. Should the total number of registered KOH drivers not exceed 100 drivers, it is possible for additional LCQ participants to qualify. However, should the maximum number of registered drivers meet or exceed 100 drivers no more than 10 LCQ participants will advance. Any driver who pays an LCQ registration who qualifies at any of the remaining 2012 qualifiers will have their entire LCQ entry fee applied towards their 2013 King of the Hammers entry fee. Team Name_________________________________ Car Number_________________________________ Home Town_________________________________ Driver of Record______________________________ Co-Driver ___________________________________ Chassis Builder_______________________________ Engine______________________________________ Transmission_________________________________ Transfer Case________________________________ Front Axle and Locker__________________________ Rear Axle and Locker__________________________ Wheels_____________________________________ Tires________________________________________ Shocks______________________________________ Seat Manufacturer_____________________________ Race radio Frequency___________________________ 1 Team Biography; limited to 50 words or less. __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ Please submit an electronic image of your team, race car, Driver of record head shot, and title sponsor logo to [email protected] Driver of record___________________________________________ Birth date_________________________________________________ Home address_____________________________________________ City/State/zip______________________________________________ Email ____________________________________________________ Home Phone_______________________________________________ Cell Phone_________________________________________________ Emergency contact _________________________________________ Emergency contact Number__________________________________ Relationship to driver of record________________________________ Known Medical conditions; ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ Co-Driver _______________________________________________ Birth date_________________________________________________ Home address_____________________________________________ City/State/zip______________________________________________ Email ____________________________________________________ Home Phone_______________________________________________ Cell Phone_________________________________________________ Emergency contact _________________________________________ Emergency contact Number__________________________________ Relationship to driver of record________________________________ Known Medical conditions; ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ Co-Driver ________________________________________________ Birth date_________________________________________________ Home address_____________________________________________ City/State/zip______________________________________________ Email ____________________________________________________ Home Phone_______________________________________________ Cell Phone_________________________________________________ Emergency contact _________________________________________ Emergency contact Number__________________________________ Relationship to driver of record________________________________ Co-Driver ________________________________________________ Birth date_________________________________________________ Home address_____________________________________________ City/State/zip______________________________________________ Email ____________________________________________________ Home Phone_______________________________________________ Cell Phone_________________________________________________ Emergency contact _________________________________________ Emergency contact Number__________________________________ Relationship to driver of record________________________________ 2 Known Medical conditions; ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ Known Medical conditions; ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ALL RACE PARTICIPANTS MUST SIGN ADDITIONAL PAGES OF THIS FORM WAIVER INDEMNIFICATION AND RELEASE; REMEMBER: OFF-ROAD RACING IS A FUN BUT DANGEROUS SPORT. YOU COULD BE SERIOUSLY INJURED, CRIPPLED, OR KILLED. I, THE UNDERSIGNED, DO HEREBY DECLARE THAT THE DRIVER AND CO-DRIVERS LISTED ON THIS ENTRY FORM POSSESS THE STANDARD OF COMPETENCE NECESSARY AND ARE PHYSICALLY FIT FOR AN EVENT OF THIS TYPE FOR WHICH THIS ENTRY RELATES AND THAT THE VEHICLE ENTERED IS TECHNICALLY LEGAL FOR RACING Ultra4 EVENTS, AND SAFE FOR THIS EVENT. I UNDERSTAND THAT THE AREA IS AN OPEN OHV AREA AND SPECTATORS MAY BE ON TRAVELLING ON THE RACE COURSE AT ANY GIVEN TIME. I WILL ADJUST MY SPEEDS AS NEEDED TO REMAIN IN CONTROL OF MY RACE VEHICLE AT ALL TIMES. I understand that as a condition to my participation in the 4 Wheel Parts LCQ and GRIFFIN King of the Hammers 2013, I am releasing Hammerking Productions Inc., Dave Cole, and its volunteers, and sponsors from all responsibilities to heirs executors assigns and me for anything that occurs during the event. It is my intention that this release extends to my use of any and all related facilities including, but not limited to, my use of the course and related facilities for pre-running of the course. I, the undersigned, do hereby for myself, my heirs, executors and assigns, AGREE WITH Hammerking Productions Inc., AS FOLLOWS: I UNDERSTAND THAT OFF-ROAD RACING IS A DANGEROUS ACTIVITY. I ALSO UNDERSTAND THAT BY PARTICIPATION IN THE EVENT AND IN PRE-RUNNING ACTIVITIES I AM EXPOSING MYSELF TO THE POSSIBILITY OF SERIOUS INJURY TO MY PERSON AND MY PROPERTY. I VOLUNTARILY ACCEPT THOSE RISKS OF INJURY. I UNDERSTAND THAT LIABILITY INSURANCE IS FOR THE THIRD PARTY COVERAGE ONLY. AS A RESULT OF A RATE OR REQUIREMENT INSURANCE, IT MAY BE NECESSARY TO INCREASE THE COST OF INSURANCE. I UNDERSTAND THAT I MAY BE AT RISK FOR LIABILITY OF MY ACTIONS AS A RESULT OF MY PARTICIPATION IN THIS EVENT. I HEREBY REMISE, RELEASE AND FOREVER DISCHARGE Hammerking Productions Inc., THEIR OFFICERS, AGENTS, OFFICIALS AND VOLUNTEERS FROM ALL ACTION, CAUSES OF ACTION, CLAIMS, AND DEMANDS WHATSOEVER, WHICH MIGHT ARISE OUT OF, OR RESULT FROM MY PARTICIPATION IN THIS EVENT AND MY USE OF ANY AND ALL RELATED FACILITIES INCLUDING, BUT NOT LIMITED TO, THE USE OF THE COURSES AND SUCH RELATED FACILITIES FOR PRE-RUNNING ACTIVITIES. I ALSO AGREE TO INDEMNIFY AND HOLD HARMLESS Hammerking Productions Inc., FROM ALL SUCH CLAIMS OR RIGHT OF ACTION. I UNDERSTAND THAT THE ENTRY FEE DOES NOT PROVIDE LIABILITY PROTECTION FOR ANY PARTICIPANT IN 4 Wheel Parts LCQ or GRIFFIN King of the Hammers 2013. I intend that the release, indemnify and hold harmless described in the previous paragraph shall cover any claim or demand for injury to or death of any person. The release shall also apply to any damage to or destruction of property including but not limited to, injury to me or my property. My release, indemnity and hold harmless SPECIFICALLY INCLUDES INJURY, DAMAGE, AND DESTRUCTION TO ANY PERSONS OR PROPERTIES WHICH MAY ARISE OUT OF ANY NEGLIGENT ACTS OR OMISSION OF their individuals, officers, agents, officials and volunteers. By signing this Waiver, Indemnification and Release, I do not release anyone from any damage I may suffer from intentional acts designed to harm me or my property. I do release Hammerking Productions Inc., from liability that might be imposed on them by law for such acts of theirs that they, Hammerking productions Inc. have not directed, adopted or ratified. The course markings apply only to the 4Wheel Parts LCQ, GRIFFIN King of the Hammers 2013 AND 2013 KOH UTV RACE and Hammerking Productions Inc. assumes no responsibility for any damage caused by rearrangements or redirection of the course marking caused by event participation, other individual, and natural or other causes. I have completely read the foregoing Waiver, Indemnification and Release and fully understand that no officer, volunteer or any other agent of Hammerking Productions Inc. is authorized to vary any term or provision of the release contrary to its provisions and I should not rely on any such variance or representation. I hereby certify that I have completely read the Rules and Regulation Waiver of Hammerking Productions Inc., and this entry form, and that I agree with and shall comply with all the Rules and Regulations of Hammerking Productions Inc. INDEMNIFICATION AND RELEASE I, the undersigned, do hereby for myself, my heirs, executors and assigns, release, remiss and forever discharge and agree to indemnify and hold harmless individuals, officers, agents, sponsors, sanctioners, co-sanctioners, servants and employees of and from any and every claim, demand, action or right of action of whatsoever kind or nature and any cost, loss or expense in connection wherewith arising from or any person or any damage to or destruction of any property resulting from or claim to result from or arise out of accident or occurrence during or in connection with said use, including specifically such as may arise out of our be claim to arise out of negligence on the part of said Hammerking Productions Inc., its individuals, officers, agents, sponsors, co-sponsors, sanctioners, co -sanctioners, servants and employees. This Waiver and Indemnification and Release is given and this agreement is made in consideration and as a condition permitting the undersigned to use course or circuit facilities or act as an official or spectator or participants or to be present in any other capacity whatsoever at said event. I have read the foregoing Waiver, Indemnification and Release and fully understand that no officer or agent or employee of Hammerking Productions Inc., is authorized to vary the terms or provisions of this instrument or to make any representations contrary to the provisions hereof. “I declare that the driver or co-drivers listed on this entry application possesses the standard of competence necessary and is physically fit for an event of this type for which this entry relates and that the vehicle entered is road worthy and suitable for this event.” I agree to meet the requirements of Hammerking Productions Inc regarding media day, and will make myself and team if required available for pre race and post race interviews. I HAVE READ AND FULLY UNDERSTAND THIS ENTRY AND RELEASE FORM AND THE CONTENTS THERETO. I HAVE READ AND FULLY UNDERSTAND THIS ENTRY AND RELEASE FORM AND THE CONTENTS THERETO. Driver of Record Signature Co-Driver #1 Signature Date; Date; I HAVE READ AND FULLY UNDERSTAND THIS ENTRY AND RELEASE FORM AND THE CONTENTS THERETO. I HAVE READ AND FULLY UNDERSTAND THIS ENTRY AND RELEASE FORM AND THE CONTENTS THERETO. Co-Driver #2 Signature Co-Driver #3 Signature Date; 3 Date; I acknowledge that myself, my likeness, or my race/support vehicle appeared or shall appear in certain video footage (the "Footage") which is intended to be used in conjunction with the projects now known as King Of The Hammers 2013, King of the Hammers, King of the Hammers 4 Wheel parts last Chance Qualifier, and related Ultra4 racing projects (collectively or separately known as the “Project”), produced by King Of The Hammers, Hammerking Productions Inc., Pinned, Eight East Inc., Heavy Metal Concepts, and all their licensees, successors and assigns, (the “Company”) photographic, or motion picture for televised broadcast, theatrical release, marketing campaigns, magazine, or newspaper coverage, and/or inclusion on DVDs, VHS, downloads and streaming through websites and/or the internet in motion picture or still photography. I acknowledge and agree as follows: Company shall have the exclusive right, throughout the universe, in perpetuity, free of charge, to embody the Footage in any video/film, any and all audio-visual devices and other derivatives and reproductions thereof, and any and all related advertising and promotional materials (collectively the "Film"), and to copyright, exhibit, broadcast, distribute, sell, rent, and otherwise use and exploit the Film by any and all means, in any medium or form, whether now or hereafter known, either alone or coupled with other materials. Company shall have the right (but not the obligation) throughout the universe, in perpetuity, to use my name and likeness in connection with any use or exploitation of the film I warrant and represent that I have the right to grant the rights granted hereunder, and I shall indemnify you for any damages incurred as a result of any breach of my warranties, representations and agreements hereunder. The undersigned acknowledges that it has read and understands the foregoing, and that upon signing its name below, this document shall become legally binding. I HAVE READ AND FULLY UNDERSTAND THIS ENTRY AND RELEASE FORM AND THE CONTENTS THERETO . Driver of record Signature Date; Print name I HAVE READ AND FULLY UNDERSTAND THIS ENTRY AND RELEASE FORM AND THE CONTENTS THERETO . Co– Driver Signature Date; Print name I HAVE READ AND FULLY UNDERSTAND THIS ENTRY AND RELEASE FORM AND THE CONTENTS THERETO. I HAVE READ AND FULLY UNDERSTAND THIS ENTRY AND RELEASE FORM AND THE CONTENTS THERETO. Pit-Crew Signature Pit-Crew Signature Date; Print name Date; Print name I HAVE READ AND FULLY UNDERSTAND THIS ENTRY AND RELEASE FORM AND THE CONTENTS THERETO. I HAVE READ AND FULLY UNDERSTAND THIS ENTRY AND RELEASE FORM AND THE CONTENTS THERETO. Pit-Crew Signature Pit-Crew Signature Date; Print name Date; Print name I HAVE READ AND FULLY UNDERSTAND THIS ENTRY AND RELEASE FORM AND THE CONTENTS THERETO. I HAVE READ AND FULLY UNDERSTAND THIS ENTRY AND RELEASE FORM AND THE CONTENTS THERETO. Pit-Crew Signature Pit-Crew Signature Date; Print name Date; Print name I HAVE READ AND FULLY UNDERSTAND THIS ENTRY AND RELEASE FORM AND THE CONTENTS THERETO. I HAVE READ AND FULLY UNDERSTAND THIS ENTRY AND RELEASE FORM AND THE CONTENTS THERETO. Pit-Crew Signature Pit-Crew Signature Date; Print name Date; Print name I HAVE READ AND FULLY UNDERSTAND THIS ENTRY AND RELEASE FORM AND THE CONTENTS THERETO. I HAVE READ AND FULLY UNDERSTAND THIS ENTRY AND RELEASE FORM AND THE CONTENTS THERETO. Pit-Crew Signature Pit-Crew Signature Date; Print name 4 Date; Print name Please make checks payable to; Hammerking Productions Inc. Mail to; Hammerking Productions Inc. 1040 Mt. Vernon Ave. , Suite G-309 Colton, CA 92324 2013 4Wheel Parts Last Chance Qualifier 9/15-10/15 $400 $_____ 2013 4Wheel Parts Last Chance Qualifier 10/16-11/15 $450 $_____ 2013 4Wheel Parts Last Chance Qualifier 11/16-12/15 $600 $_____ 2013 Ultra4 racing Membership fee (if qualified) Onsite 2013 Griffin King of the Hammers Entry fee (if qualified) Onsite IRC Entry Fee (if qualified) Onsite Entry into the 2013 4WP LCQ is limited to the first 60 teams in order they are received. Hammerking will not accept phone calls as place holders into LCQ. Hammerking Productions is not responsible for lost or stolen checks. Entry fees are non refundable. Entry invitation is non transferable. Teams that advance to the main event will need to pay balance of fees directly following the LCQ winners announcement. ( Cash Only) Ultra4 Membership is for the calendar year of 2013, and non refundable. Ultra4 membership is applicable at all Ultra4 racing sanctioned events. Additional memberships may be required at selected events in the 2013 schedule. Winners Purse may vary at each Ultra4 racing event. Advancing teams will be able to credit $200 towards the 2013 King of the Hammers race entry fee. Cash only. Payable following the announcement of LCQ qualified teams. The 4Wheel Parts Last Chance Qualifying guarantees at least 10 teams will advance to the 2013 Griffin King of The Hammers. Should the total number of registered KOH drivers not exceed 100 drivers, it is possible for additional LCQ participants to qualify. However, should the maximum number of registered drivers meet or exceed 100 drivers no more than 10 LCQ participants will advance. Any driver who pays an LCQ registration who qualifies at any of the remaining 2012 qualifiers will have their entire LCQ entry fee applied towards their 2013 King of the Hammers entry fee. Pit tent rental, and additional race related information to follow. Please visit ultra4racing.com for more information. Teams will be required to check in to Hammerking onsite to receive the course map. GPS downloads will require a team supplied SD card 2 GB or I HAVE READ AND FULLY UNDERSTAND THIS ENTRY AND RELEASE FORM AND THE CONTENTS THERETO. Driver of Record Signature 5 Date;
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