May 28, 2010 Practice Day Application
The MARRC Practice Day is for licensed racers and Street Riders. Racers must show your license when you sign in at the track.
First Name:			Last Name:
Street:
City:		State:	Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Neveda 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	Zip:
E-mail Address: (valid email)
Home Phone:			Work Phone:
Date of Birth:
Emergency Contact:			Number:
Have you ever been a MARRC member?   yes no				Member #
What motorcycle (s) do you plan to use for the practice day? Make: Model: Year: Do you have a race license? license type (Ex/Am) or Street Rider: Number: Bike CCs:   I acknowledge that I am fully aware of the hazards and dangers involved in motorcycle road racing. I hereby assume all risks involved in my participation on this event. I hereby indemnify and agree to hold MARRC, its officers, agents, members, servants, volunteers, and/or employees harmless of and from any and all claims, demands, actions, causes of action or suits of any kind or nature, whatsoever, now, or at any time in the future related to participating in the MARRC Practice Day. For your convenience you are now accepting PayPal as form of payment. You may either mail-in your payment or use the PayPal button on the next page. MAIL DEPOSIT TO: MARRC-Practice Day Attn: Rick Beggs 45700 Woodland Rd., unit 160, Sterling, VA 20166