SEMRA 2011 Competition License Application

Name: _______________________________Phone:_________

Street Address:_______________________________________

City, State, Zip:_______________________________________

E-mail Address:__________________________ D.O.B._______

Requested Number Choice 1______2______3______4______

Have you ever held a roadracing license?____ What Org?______

I have read this application in its entirety and stipulate, under the penalty of perjury, that all statistical information set forth herein by me is true and accurate and complete.

In consideration for granting me a competition license by the Southeast Mini Roadracing Association, LLC (hereafter referred to as SEMRA), and in consideration of the promotion and operation of roadrace events by SEMRA, and in consideration of granting of permission to enter, use and remain on the track facilities and/or premises at which these events take place by the owners and representatives thereof, I hereby, for myself, my heirs, personal representatives and assigns, release, discharge, and agree to hold blameless and indemnify SEMRA, it痴 representatives, the owners and representatives of the aforementioned track facilities and/or premises, as well as directors, officers, agents, employees and/or members of all of them and from any liability, loss, claims, demands and possible causes of action that may otherwise accrue from any loss, damage, injury (including death) to my person and property, in any way a result from, or arising in connection with, or related to any event, and whether arising, while engaged in competition or in practice or preparation thereof, while upon entering or departing from said track facilities and or premises, from any cause whatsoever including without limitation, the failure of anyone to enforce rules or regulations, failure to make inspections, of the negligence of other persons.  I understand that motorcycle racing competition can constitute a hazardous activity and that by reason of my application for a SEMRA roadrace license and /or participation in or presence at any competition event, I am assuming all risks and hazards related thereto.

I agree that SEMRA may use my name and likeness, including pictures of my racing equipment and pictures taken at any event, for the purpose of media and promotion.  I agree to abide by SEMRA rules and respect the authority of the race officials and personnel at all events. 

I hereby confirm, consent and agree to the Foregoing.