12.3 NCCC REGISTRATION FORM

Host Club/location: / NICC & Sunburst / Sanction #(s): / MW-167-133 / 134
MW-277-135/ 136 / 137
Registration (Car) Number/s:
Events Registering For: (If registering for all the events, go directly to requested driver information section of the form, otherwise complete below)
All Events: / One person: / Two persons:
Concours: / Rallye: / Economy Run: / Funkhana:
Drag Races: / Driver #1: / Driver #2:
Autocross Low Speed: / Driver #1: / Driver #2:
Autocross High Speed: / Driver #1: / Driver #2:
Matching Times (MT): / Driver #1: / Driver #2:
Driver #1: / NCCC #:
Address: / Club Name:
City: / State: / Zip Code: / Phone:
Check here if Navigator for -- Rallye: / Economy Run: / Funkhana:
Driver #2: / NCCC #:
Address: / Club Name:
City: / State: / Zip Code: / Phone:
Check here if Navigator for -- Rallye: / Economy Run: / Funkhana:
E-Mail Address to send results to:
Whom do you wish to notify in case of Emergency?
(Leave blank if a member of your Club, at the event, will act as your contact person.)
Name: / Relationship: / Phone:
Fill out below for all events:
Year of Car: / Make: / Style:
Class normally entered in:
(List any changes that may affect classification on reverse side of this sheet.)
Fill out below for all events except Concours, Funkhana and Rallye:
Factory Rated HP: / Displacement: / Transmission type:
Drive Axle Ratio: / Tire Size & Type -- F: / R:
NOTES: 1. All entrants MUST completely and truthfully fill out the registration form. All entrants eighteen (18) years and older MUST also sign the Release and Waiver of Liability, Assumption of Risk and Indemnity Agreement and any other release documents which maybe required by NCCC. Entrants younger than eighteen (18) years old must have a parent or legal guardian present and submit a properly completed Parental Consent, Release and Waiver of Liability, Assumption of Risk, and Indemnity Agreement and a Minor's Assumption of Risk Acknowledgment and any other release documents which maybe required by NCCC. 2. All drivers must be properly licensed per Section 1.7.1. (Eligibility to Compete) of the NCCC Rulebook.
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