Crew Member Registration | Scoring.Racing

Register Crew Member

This information will let us know more about you.

Crew Member
Emergency
Options
Association
Finish

Crew Information

Crew First Name

Crew Last Name

Suffix

Address Line 1

Address Line 2

Postal Code

City

State

Primary Phone no dashes or spaces

Primary Email

Emergency Contact

Information is only shared with EMT staff.

Emergency First Name

Emergency Last Name

Primary Phone no dashes or spaces

Preferred Hospital

Primary Doctor

Notes

Medications

By filling this form, I understand that the information used or disclosed may be subject to re-disclosure by the person or class of person or facility receiving it, and would then no longer be protected by federal privacy regulations
I may revoke this authorization by notifying the track/series in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions

Select	Name Select all that apply	Price
	Line Total	$0.00
	Processing Fee	$0.00
	Total	$0.00

Driver Association

Who will you working with?

I am a

Division I am with

Car Number

Driver Association

Payment

Card

Name on the Card Name as it appears on the card

Postal Code for Card 5 Digit Postal Code for the card

Consent to follow the rules.

Consent to electronic signature
I agree to all rules and terms of the Jefferson Speedway.

Coupon Code

Processing Fee: $0.00

Total: $0.00

You registration is protected