Chapel Hill Raceway

Driver Registration and Divisional Entry Form

Registration Fee :  $40 per Class

Please make checks payable to : Great Valley Kart Club, 36 Mill St. Ellicottville, NY 14731

Driver Information :

Name : _________________________WKA License Number : ___________

Address : _________________________

City : _________________________Date of Birth :___________

State/Province :______ Zip : __________ Age as of 1/1/07 :________

Email Address : _____________________

Phone Number : _____________________ Fax:____________

Emergency Contact :

Name : ___________________________

Relationship : ___________________________

Phone Number : ___________________________

Racing Class Chassis Model Chassis Year Racing Number

___________ ___________ __________ _____________

___________ ___________ __________ _____________

___________ ___________ __________ _____________

___________ ___________ __________ _____________

Please list any sponsors or special acknowledgements :

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