2020 Big Bend Open Road Race Entry Packet · 2020 Big Bend Open Road Race Entry Packet Form-101...

2020 Big Bend Open Road Race

Entry Packet

Form-101 (Rev. 12/11/2019) Form available online at www.BBORR.com of 5

General Instructions

This form must be completed and submitted to the Race Coordinator accompanied by any required supporting documents. An application form may be reproduced or faxed. A completed form must contain the signature or electronic signature of the driver and navigator/ co-driver.

AVAILABLE HELP

For assistance in completing this form, contact Crystal Lopez at 432-336-2264 or [email protected]

Forms of Submissions

Email:

[email protected]

Fax:

432-336-6114

Mail: Big Bend Open Road Race

P.O. Box 416 Fort Stockton, TX 79735

Notice

The Big Bend Open Road Race is more of a technical driver’s challenge than a straight road course like other open road races. There is 59 turns in the last 50 miles leading to Sanderson, Texas. The course is composed of many turns and elevation changes. These turns make it a real challenge to meet your average class speed in any division. Please keep this in mind when you decide on your entry Division and Class.

Refund and Transfer Policy

1. Memberships are non-refundable and non-transferable.

2. All cancellations and requests for refund must be made in writing to the Big Bend Open Road Race P.O. Box 416 Fort Stockton, TX 79735 or by email at [email protected]. All refunds will be issued in the form of a check. Please allow 10 business days for processing of refund.

3. Entries canceled at least 30 days prior to the event are eligible for a refund. Entries will be refunded minus the membership fees and a 10% handling fee.

4. Entries canceled at least 14 days prior to the event are eligible for a refund of 50% of their paid entry fees minus the membership fees and a 10% handling fee.

5. No refund option is available to entries canceled within 13 days of the event. a) All fees will be forfeited for entries canceled within 13 days of the event. b) Event “NO-SHOW” forfeit all fees. c) NO EXEPTIONS

By signing the entry application and thereby entering the event, you are certifying your understanding and acceptance of these terms. It is imperative that if you do not understand one or any of the above stated polices and/or need clarification, that you contact the Race Coordinator Crystal Lopez.

Big Bend Open Road Race will make every effort to insure that the event will be started and completed in a timely manner. There may be occasions where Acts of God or Government Intervention may prevent the start and/or completion of the event. If such an occasion were to arise, Big Bend Open Road Race cannot issue refunds or rain checks.

This is to let you know that by submitting an electronic signature, you are providing an electronic mark that is held to the same standard as a legally binding equivalent of a handwritten signature provided by you. A digital mark is considered a typed legal First and Last name (legal name may include middle name, initial or suffix) followed by the typed date.

Part A: Participant/ Vehicle Information A


Driver Information First Name:

Last Name:

Nickname:

Suffix (if any):

Date of Birth:

Mailing Address:

City:

State/ Province:

Zip:

Country:

Home Phone:

Mobile Phone:

Email Address:

Dietary Needs:

Navigator/ Co-Driver Information First Name:

Last Name:

Nickname:

Suffix (if any):

Date of Birth:

Mailing Address:

City:

State/ Province:

Zip:

Country:

Home Phone:

Mobile Phone:

Email Address:

Dietary Needs:

Navigator/ Co-Driver Question Yes No

Will navigator be driving on return leg?

! Every driver and co-driver must attach a valid copy of their driver’s license with this application. Also with this application a valid copy of automobile insurance for the vehicle intended to race

must be attached. !

Driver Competition History Big Bend Open Road Race Rookie Year:

Big Bend Open Road Race Rookie Speed:

Organization:

Date:

Organization:

Date:

Organization:

Date:

Navigator/ Co-Driver Competition History Big Bend Open Road Race Rookie Year:

Big Bend Open Road Race Rookie Speed:

Organization:

Date:

Organization:

Date:

Organization:

Date:

Part A: Participant/ Vehicle Information A


Car Number Choice #1:

Choice #2:

Choice #3:

Davison\ Class Unlimited (UNL) UNL

Super Sport (SS) 155 160

Grand Sport (GS) 130 135 140 145 150

Grand Touring (GT) 115 120 125

Touring (T) 100 105 110

Street Rod (SR) 85 90 95

Installed Safety Equipment Racing Harness:

Roll Bar:

Roll Cage:

Fuel Cell:

Fire Extinguisher:

Fire Suppression System:

Vehicle Information Year:

Make:

Model:

Body Style:

Major Color:

Minor Color:

Stock:

Stock Modified:

Purpose Built Race Car:

Year Built:

Fuel Type:

Tire Year: Tire Date:

By signing the fields below I certify that the enclosed and attached information above is correct and understand that any misrepresentation is grounds for disqualification from the event and forfeiture of my entry fee. I also certify that I have reviewed and accept the terms of the Big Bend Open Road Race refund/ transfer policy as outlined in this entry packet. Furthermore I have read the rules, regulations, and technical specifications for this event and understand that safety of my vehicle is my responsibility. Driver Signature: *

Date:

Navigator/ Co-Driver Signature: *

Date:

* I agree that my electronic signature is the legally binding equivalent to my handwritten signature. Whenever I execute an electronic signature, it has the same validity and meaning as my handwritten signature. I will not, at any time in the future, repudiate the meaning of my electronic signature or claim that my electronic signature is not legally binding.

Part B: Entry Fees/ Payment Information B

Form-101 (Rev. 12/11/2019) Form available online at www.BBORR.com Page 3 of 5

Description: Price: Qty: Total:

¹Street Rod Division (SR) $500.00

¹Touring Division (T) $600.00

¹Grand Touring Division (GT) $700.00

¹Grand Sport Division (GS) $800.00

¹Super Sport Division (SS) $900.00

¹Unlimited Division (UNL) $1000.00

¹Navigator/ Co-Driver Participation Fee $200.00

Licensed Driver Practice $200.00

²Rookie Orientation & Qualifying Practice $250.00

Lifetime Car Number Car Number:

$100.00

Award Banquet Additional Tickets $50.00

Membership Dues $50.00

Speed Certificate (8 ½” x 11) $40.00

BBORR Patch $15.00

Commemorative Race Polo Size:

Name (Optional $15):

$45.00

Size:


Size:


Size:


T-Shirts Driver: Size:

Style:

Color:

Navigator/ Co-Driver: Size:

Style:

Color:

Official Race Course DVD (Highway 285 & 90)

Team Challenge Team Name:

Total:

¹ One banquet ticket included in fee. ² Practice runs are included in fee.

Crystal Lopez

Cross-Out

Part B: Entry Fees/ Payment Information B


!

CUSTOMER NOTICE: THERE IS 3.99% CUSTOMER SERVICE CHARGE ON ALL OUR SALES AND SERVICES.

AS AN INCENTIVE, CUSTOMERS WHO PAY WITH CASH/ CHECK/ AND MONEY ORDER RECEIVE AN IMMEDIATE CASH DISCOUNT OF 3.99%.

!

Method of Payment

Checks/ Cashier’s Checks or Money Orders should be made out to Big Bend Open Road Race

Check (Enclosed) Cashier’s Check or Money Order (Enclosed)

Discover MasterCard Visa American Express

Credit/Debit Card Number (No Dashes):

Name as Printed on the Credit/Debit Card:

Expiration Date: CVC2/CVV2/CSC:

Total Amount:

$

By signing the field below are authorizing the Big Bend Open Road Race to charge your credit card noted above for the agreed upon purchases. Card Holder Signature: *

Date:

! If Navigator/ Co-Driver is paying for their entry fees separate please use form below. !

Method of Payment

Checks/ Cashier’s Checks or Money Orders should be made out to Big Bend Open Road Race

Check (Enclosed) Cashier’s Check or Money Order (Enclosed)

Discover MasterCard Visa American Express

Credit/Debit Card Number (No Dashes):

Name as Printed on the Credit/Debit Card:

Expiration Date:

CVC2/CVV2/CSC:

Total Amount:

$

By signing the field below are authorizing the Big Bend Open Road Race to charge your credit card noted above for the agreed upon purchases. Card Holder Signature: *

Date:


Part C: Driver Medical Information Form C


First Name:

Middle Name:

Last Name:

Suffix (if any):

Date of Birth:

Street Address:

City:

State/ Province:

Zip:

Country:

Gender:

Height (inches):

Weight (lbs.):

Health History

Yes No Condition Explain

Abdominal/ stomach/ digestive problems

Asthma Last attack date:

Congenital heart disease/heart attack/ chest pain/ heart murmur/ coronary artery disease

Diabetes Last HbA1c percentage and date:

Extensive confinement

Fainting spells and dizziness

Head injury/ concussion/ spinal injury

Kidney disease

Lung/ respiratory disease

Psychiatric/ psychological

Permanent defect from illness/ disease

Seizures Last seizure date:

List any other medical conditions not covered above

Yes No Allergies or Reactions Explain

Medications

Food

Plants

Insect bites/stings

Medication Dose Frequency Reason

Normal Abnormal Explain Abnormalities

Eyes

Ears

Lungs

Heart

Part C: Driver Medical Information Form C


Physician Information Physician Name:

Street Address:

City:

State/ Province:

Zip:

Country:

Office Phone:

! In case of emergency, notify the person below !

Emergency Contact Information First Name:

Middle Name:

Last Name:

Relationship:

Street Address:

City:

State/ Province:

Zip:

Country:

Home Phone:

Mobile Phone:

I do _____ give Big Bend Open Road Race permission to permission to release my medical information/physical form to emergency personnel.

I do not _____ give Big Bend Open Road Race permission to release my medical information/physical form to emergency personnel.

I certify that the above information is true and complete and further certify that there is no reason physically or mentally that would preclude me from participating and driving in the Big Bend Open Road Race. Driver Signature: *

Date:


Part D: Navigator/ Co-Driver Medical Information Form D


First Name:

Middle Name:

Last Name:

Suffix (if any):

Date of Birth:

Street Address:

City:

State/ Province:

Zip:

Country:

Gender:

Height (inches):

Weight (lbs.):

Health History

Yes No Condition Explain

Abdominal/ stomach/ digestive problems

Asthma Last attack date:

Congenital heart disease/heart attack/ chest pain/ heart murmur/ coronary artery disease

Diabetes Last HbA1c percentage and date:

Extensive confinement

Fainting spells and dizziness

Head injury/ concussion/ spinal injury

Kidney disease

Lung/ respiratory disease

Psychiatric/ psychological

Permanent defect from illness/ disease

Seizures Last seizure date:

List any other medical conditions not covered above

Yes No Allergies or Reactions Explain

Medications

Food

Plants

Insect bites/stings

Medication Dose Frequency Reason

Normal Abnormal Explain Abnormalities

Eyes

Ears

Lungs

Heart

Part D: Navigator/ Co-Driver Medical Information Form D


Physician Information Physician Name:

Street Address:

City:

State/ Province:

Zip:

Country:

Office Phone:

! In case of emergency, notify the person below !

Emergency Contact Information First Name:

Middle Name:

Last Name:

Relationship:

Street Address:

City:

State/ Province:

Zip:

Country:

Home Phone:

Mobile Phone:

I do _____ give Big Bend Open Road Race permission to permission to release my medical information/physical form to emergency personnel.

I do not _____ give Big Bend Open Road Race permission to release my medical information/physical form to emergency personnel.

I certify that the above information is true and complete and further certify that there is no reason physically or mentally that would preclude me from participating and driving in the Big Bend Open Road Race. * Driver Signature:

* Date:

* This Acknowledgement and Certification of Understanding ("Acknowledgement") is to let you know that by submitting an electronic signature, you are providing an electronic mark that is held to the same standard as a legally binding equivalent of a handwritten signature provided by you. For purposes of the acknowledgement, a digital mark is considered a typed legal First and Last name (legal name may include middle name, initial or suffix) followed by the typed date.

2020 Big Bend Open Road Race Entry Packet · 2020 Big Bend Open Road Race Entry Packet Form-101...

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Transcript of 2020 Big Bend Open Road Race Entry Packet · 2020 Big Bend Open Road Race Entry Packet Form-101...