Register Driver
This information will let us know more about you.
To complete the registration. Please have the following available:
Tax information (Social or Tax ID) & Sponsor information.
Driver
Emergency
Divisions
Media
Car(s)
Crew
Finish
Driver Information
Driver First Name
Driver Last Name
Suffix
Sr
Jr
III
Address Line 1
Address Line 2
Postal Code
City
State
Select State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
District of Columbia
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Primary Phone
no dashes or spaces
Text Message Consent
Agree to SMS
Get lineup text messages
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
Divisions Select all divisions that apply
All Options
Bandit
Bandoleros
Hobby Stock
International
Late Model
Legends
Sportsman
6 Shooters
Select
Name
Select all that apply
Qty
Price
Additional Adult Ticket
$30.00
Banquet Adult Ticket
1
$30.00
Kids Under 12 Ticket
$15.00
Line Total
$0.00
Processing Fee
$0.00
Total
$0.00
Media
Just some information for the announcer
Name Pronunciation
Weekly Home Track
Home Town
Age
Years Racing
Accomplishments
Car Information
Crew Information
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.
I can view the
terms and rules here
I agree to all rules and terms of the Jefferson Speedway.
Coupon Code
apply discount
Processing Fee:
$0.00
Total:
$0.00