MEMBERSHIP APPLICATION
MID-STATE KART CLUB
PRINTABLE VERSION

Give to any officer or
Mail to:  Mid-State Kart Club, Inc.
             P.O. Box 312
             Springfield, IL 62705

In order to participate as a member of Mid-State Kart Club, Inc. you are obligated to pay an annual membership fee of $100.00, plus a one-time $100.00 initiation fee for new members.  Although you may race and practice at Mid-State Kart Club, Inc. you will be charged the non-membership fee for such until membership payment is received.  A non-racing membership is available for $50.00, plus a one-time $100.00 initiation fee for new members.  
While racing or practicing at Mid-State Kart Club, Inc., whether a member or non-member, I agree to comply with all rules, policies and procedures as printed in the Mid-State Kart Club Program and WKA Rulebook.  Program booklets are available to all participants of Mid-State Kart Club, Inc.  WKA Pocket Rulebooks are available to all paid members.  It is my responsibility to read and understand said rules, policies and procedures.  
Although safety is the highest priority at Mid-State Kart Club, Inc., accidents do happen in spite of actions taken to prevent them.  Participants at Mid-State Kart Club, Inc. will at no time hold Mid-State Kart Club, Inc., or any of its officers liable for any personal injury or property damage that may occur when practicing or racing at the club.  
 

DATE:

SIGNATURE:

MEMBER'S NAME:

RACING > $

NON-RACING > $

ADDRESS:

CITY, STATE, ZIP CODE:

PHONE:

BIRTHDAY (MM/DD/YYYY):

E-MAIL ADDRESS:

DRIVER'S NAME:

BIRTHDAY:

FAMILY MEMBER'S NAME(S):	BIRTHDAY FOR EACH (MM/DD/YYYY):

KID KART AND JUNIOR 1 PARTICIPANTS MUST HAVE PROOF OF AGE

CHECK #:	DATE:
OFFICER: