FMSA c/o Jesse Teed
21103 Reindeer Rd.
Christmas, Fl 32709
2010 Membership Application
Driver/Owner: ___________________/______________________ Car #: _______ or ________
Name: __________________________________________________
Address: _______________________________________________
City, State, Zip Code: _______________________________________________
Sponsors: ______________________________________________
Chassis:_______________________________ Engine ____________________ cc
Date of Birth: _______/______/19_______ S.S.N.: _______-_____-_______
PH.#:(_______) _______-_________ EMAIL: ____________________________
Employer: _________________________ Occupation: _____________________
In Case of Emergency
Contact: __________________________________________________
Blood Type: _________________________ Allergies: _____________________
Injury release
I agree that when I participate in any Florida Mini Sprint Association event or function, I do so at my own risk and that
Florida Mini Sprint Association, officers, members, crew, participants or tracks are not responsible for any bodily injury
or any damage to property belonging to myself.
Signed: ___________________________________ Date: _______/______/2010
Membership - $100.00 – For Regular Points Race Events -Checks Payable to: FMSA
21103 Reindeer Rd.
Christmas, Fl 32709
2010 Membership Application
Driver/Owner: ___________________/______________________ Car #: _______ or ________
Name: __________________________________________________
Address: _______________________________________________
City, State, Zip Code: _______________________________________________
Sponsors: ______________________________________________
Chassis:_______________________________ Engine ____________________ cc
Date of Birth: _______/______/19_______ S.S.N.: _______-_____-_______
PH.#:(_______) _______-_________ EMAIL: ____________________________
Employer: _________________________ Occupation: _____________________
In Case of Emergency
Contact: __________________________________________________
Blood Type: _________________________ Allergies: _____________________
Injury release
I agree that when I participate in any Florida Mini Sprint Association event or function, I do so at my own risk and that
Florida Mini Sprint Association, officers, members, crew, participants or tracks are not responsible for any bodily injury
or any damage to property belonging to myself.
Signed: ___________________________________ Date: _______/______/2010
Membership - $100.00 – For Regular Points Race Events -Checks Payable to: FMSA
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