Midwest Vintage Motocross 2024 Membership Application
Make check payable to Midwest Vintage MX andmail to:

Office Use Only:
Date:

Midwest Vintage Motocross LLC
2235 Newman Road
Mount Pleasant, WI 53406# Issued
Amt Rcv'd

Adult Membership $50 - Youth Membership $45 (16yrs and younger)
Membership fee must accompany this application – DO NOT SEND CASH IN THE MAIL

Name

AMA Member #Address

Date of BirthCity
Phone number (State)-//

Zipe-mailBike/Race # Choice:
1st Choice

2nd Choice

3rd Choice

Every effort will be made to give you your first number choice. If another member has taken this number you
will need to use one of your alternate choices.
RELEASE, INDEMNITY AND ASSUMPTION OF RISK AGREEMENT
Applicant acknowledges the substantial risk of injury to person and property arising from participation in motorcycling events andfurther acknowledges that such injury and damage can be caused by the negligent acts and omissions of persons and organizations
connected with the conduct of such events. Applicant hereby assumes all risk of loss, damage, or injury (including death) toapplicant's person or property from any cause whatsoever, whether or not such cause is attributable to the negligence of others.
Applicant hereby releases, discharges, and agrees to hold harmless and indemnify Midwest Vintage Motocross, sponsoring clubs, andorganizations, promoters, officials, fellow participants, land owners, and those acting in the support or on their benefit from any andall liability arising by a motorcycling event or while upon, entering or departing form the premises upon which such motorcycling
events are conducted.

NOTICE: If under 18 yrs of age, this application must be accompanied with a minor release form whichshall acknowledge a waiver and release of any and all claims such parent or guardian may have.

Riders Signature

Parent/Guardian Signature (if rider is minor)

Page 1 of 2 (PLEASE TURN OVER)

Midwest Vintage Motocross 2024 Membership Application
Emergency Information - Please Print Clearly

Do you generally travel to races alone? YES NO
Do you generally have person(s) over 18 traveling with you: YES NO
Contact in case of emergency
Relationship to rider
Emergency contact phone # (Alternate phone #())-Rider allergies: (medication, foods, etc.)
Insurance Provider:
Foreign objects rider may have in body (braces, dentures, steel rods, contacts, etc.)

Diabetic? YES NO

Blood Type (if known)

Medical Alerts or list of daily medications
HEART CONDITION OF ANY KIND?
RELEASE, INDEMNITY AND ASSUMPTION OF RISK AGREEMENT

I will not hold Midwest Vintage Motocross LLC, Woody’s Vintage GP LLC, its sponsors or its
officers or any member nor the race facility responsible for any injury, death, loss and/or theftor property damage which may occur in connection with, or as a result of any MWVMX
LLC/Woody’s Vintage GP LLC activity or event. I will be completely responsible for myself andany minor under the age of 18 whom I bring or allow to participate in a MWVMX/WVGP LLC
event or other activity. I’m also responsible for all members of my pit area. This statement also
pertains to travel to and from ANY MWVMX LLC/WVGP LLC functions.
Rider Signature
Parent/Guardian Signature (if rider is minor)