2013 4 Wheel Parts Last Chance Qualifier

CAR NUMBER
DRIVER OF RECORD
ALL RACE PARTICIPANTS MUST COMPLETE & SIGN ADDITIONAL PAGES OF THIS FORM
INCOMPLETE ENTRY FORMS WILL BE DENIED; RACE TEAM NUMBERS ARE ISSUED BASED ON A SENIORITY ONLY BASIS. NO LETTERS WILL BE
ACCEPTED (This entry form does not guarantee entry into the 2013 Griffin King of the Hammers. )
All entries must be complete including additional requested information.
Entry into the GRIFFIN King of the Hammers is limited to pre qualified drivers only. 10 Teams will advance.
This is a time sensitive document.
Entry is limited to 60 drivers
Make checks payable to:
Hammerking Productions Inc
1040 Mount Vernon Ave. Suite G-309
Colton, California 92324-4228
Entry fee is $400 if payment received 9/15-10/15, $450 payment received 10/16-11/15, $600 after 11/16.
Advancing teams will be able to credit $200 towards the 2013 King of the Hammers race entry fee. Cash only. Payable following the announcement of LCQ qualified teams. The 4Wheel Parts Last Chance Qualifying guarantees at least 10 teams will advance to the 2013 Griffin King of
The Hammers. Should the total number of registered KOH drivers not exceed 100 drivers, it is possible for additional LCQ participants to qualify. However, should the maximum number of registered drivers meet or exceed 100 drivers no more than 10 LCQ participants will advance.
Any driver who pays an LCQ registration who qualifies at any of the remaining 2012 qualifiers will have their entire LCQ entry fee applied towards their 2013 King of the Hammers entry fee.
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Team Name_________________________________
Car Number_________________________________
Home Town_________________________________
Driver of Record______________________________
Co-Driver ___________________________________
Chassis Builder_______________________________
Engine______________________________________
Transmission_________________________________
Transfer Case________________________________
Front Axle and Locker__________________________
Rear Axle and Locker__________________________
Wheels_____________________________________
Tires________________________________________
Shocks______________________________________
Seat Manufacturer_____________________________
Race radio Frequency___________________________
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Team Biography; limited to 50 words or less.
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Please submit an electronic image of your team,
race car, Driver of record head shot, and
title sponsor logo to Shannon@ultra4racing.com
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Driver of record___________________________________________
Birth date_________________________________________________
Home address_____________________________________________
City/State/zip______________________________________________
Email ____________________________________________________
Home Phone_______________________________________________
Cell Phone_________________________________________________
Emergency contact _________________________________________
Emergency contact Number__________________________________
Relationship to driver of record________________________________
Known Medical conditions;
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Co-Driver _______________________________________________
Birth date_________________________________________________
Home address_____________________________________________
City/State/zip______________________________________________
Email ____________________________________________________
Home Phone_______________________________________________
Cell Phone_________________________________________________
Emergency contact _________________________________________
Emergency contact Number__________________________________
Relationship to driver of record________________________________
Known Medical conditions;
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Co-Driver ________________________________________________
Birth date_________________________________________________
Home address_____________________________________________
City/State/zip______________________________________________
Email ____________________________________________________
Home Phone_______________________________________________
Cell Phone_________________________________________________
Emergency contact _________________________________________
Emergency contact Number__________________________________
Relationship to driver of record________________________________
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Co-Driver ________________________________________________
Birth date_________________________________________________
Home address_____________________________________________
City/State/zip______________________________________________
Email ____________________________________________________
Home Phone_______________________________________________
Cell Phone_________________________________________________
Emergency contact _________________________________________
Emergency contact Number__________________________________
Relationship to driver of record________________________________
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Known Medical conditions;
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Known Medical conditions;
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ALL RACE PARTICIPANTS MUST SIGN ADDITIONAL PAGES OF THIS FORM
WAIVER INDEMNIFICATION AND RELEASE;
REMEMBER: OFF-ROAD RACING IS A FUN BUT DANGEROUS SPORT. YOU COULD BE SERIOUSLY INJURED, CRIPPLED, OR KILLED.
I, THE UNDERSIGNED, DO HEREBY DECLARE THAT THE DRIVER AND CO-DRIVERS LISTED ON THIS ENTRY FORM POSSESS THE STANDARD OF COMPETENCE NECESSARY AND ARE PHYSICALLY FIT FOR AN EVENT OF THIS TYPE FOR
WHICH THIS ENTRY RELATES AND THAT THE VEHICLE ENTERED IS TECHNICALLY LEGAL FOR RACING Ultra4 EVENTS,
AND SAFE FOR THIS EVENT. I UNDERSTAND THAT THE AREA IS AN OPEN OHV AREA AND SPECTATORS MAY BE ON
TRAVELLING ON THE RACE COURSE AT ANY GIVEN TIME. I WILL ADJUST MY SPEEDS AS NEEDED TO REMAIN IN CONTROL OF MY RACE VEHICLE AT ALL TIMES.
I understand that as a condition to my participation in the 4 Wheel Parts LCQ and GRIFFIN King of the Hammers 2013, I am releasing Hammerking Productions Inc., Dave Cole, and its volunteers, and sponsors from all responsibilities to heirs executors assigns
and me for anything that occurs during the event. It is my intention that this release extends to my use of any and all related facilities
including, but not limited to, my use of the course and related facilities for pre-running of the course.
I, the undersigned, do hereby for myself, my heirs, executors and assigns, AGREE WITH Hammerking Productions Inc.,
AS FOLLOWS:
I UNDERSTAND THAT OFF-ROAD RACING IS A DANGEROUS ACTIVITY. I ALSO UNDERSTAND THAT BY PARTICIPATION IN THE EVENT AND IN
PRE-RUNNING ACTIVITIES I AM EXPOSING MYSELF TO THE POSSIBILITY OF SERIOUS INJURY TO MY PERSON AND MY PROPERTY. I VOLUNTARILY ACCEPT THOSE RISKS OF INJURY. I UNDERSTAND THAT LIABILITY INSURANCE IS FOR THE THIRD PARTY COVERAGE ONLY. AS
A RESULT OF A RATE OR REQUIREMENT INSURANCE, IT MAY BE NECESSARY TO INCREASE THE COST OF INSURANCE. I UNDERSTAND
THAT I MAY BE AT RISK FOR LIABILITY OF MY ACTIONS AS A RESULT OF MY PARTICIPATION IN THIS EVENT.
I HEREBY REMISE, RELEASE AND FOREVER DISCHARGE Hammerking Productions Inc., THEIR OFFICERS, AGENTS, OFFICIALS
AND VOLUNTEERS FROM ALL ACTION, CAUSES OF ACTION, CLAIMS, AND DEMANDS WHATSOEVER, WHICH MIGHT ARISE OUT OF, OR
RESULT FROM MY PARTICIPATION IN THIS EVENT AND MY USE OF ANY AND ALL RELATED FACILITIES INCLUDING, BUT NOT LIMITED TO,
THE USE OF THE COURSES AND SUCH RELATED FACILITIES FOR PRE-RUNNING ACTIVITIES. I ALSO AGREE TO INDEMNIFY AND HOLD
HARMLESS Hammerking Productions Inc., FROM ALL SUCH CLAIMS OR RIGHT OF ACTION. I UNDERSTAND THAT THE ENTRY FEE DOES
NOT PROVIDE LIABILITY PROTECTION FOR ANY PARTICIPANT IN 4 Wheel Parts LCQ or GRIFFIN King of the Hammers 2013.
I intend that the release, indemnify and hold harmless described in the previous paragraph shall cover any claim or demand
for injury to or death of any person. The release shall also apply to any damage to or destruction of property including but not limited
to, injury to me or my property. My release, indemnity and hold harmless SPECIFICALLY INCLUDES INJURY, DAMAGE, AND DESTRUCTION TO ANY PERSONS OR PROPERTIES WHICH MAY ARISE OUT OF ANY NEGLIGENT ACTS OR OMISSION OF their
individuals, officers, agents, officials and volunteers.
By signing this Waiver, Indemnification and Release, I do not release anyone from any damage I may suffer from intentional
acts designed to harm me or my property. I do release Hammerking Productions Inc., from liability that might be imposed on them
by law for such acts of theirs that they, Hammerking productions Inc. have not directed, adopted or ratified. The course markings
apply only to the 4Wheel Parts LCQ, GRIFFIN King of the Hammers 2013 AND 2013 KOH UTV RACE and Hammerking Productions Inc. assumes no responsibility for any damage caused by rearrangements or redirection of the course marking caused by event
participation, other individual, and natural or other causes.
I have completely read the foregoing Waiver, Indemnification and Release and fully understand that no officer, volunteer or
any other agent of Hammerking Productions Inc. is authorized to vary any term or provision of the release contrary to its provisions
and I should not rely on any such variance or representation. I hereby certify that
I have completely read the Rules and Regulation Waiver of Hammerking Productions Inc., and this entry form, and that I agree with
and shall comply with all the Rules and Regulations of Hammerking Productions Inc.
INDEMNIFICATION AND RELEASE
I, the undersigned, do hereby for myself, my heirs, executors and assigns, release, remiss and forever discharge and agree to indemnify and hold harmless individuals, officers, agents, sponsors, sanctioners, co-sanctioners, servants and employees of and from any
and every claim, demand, action or right of action of whatsoever kind or nature and any cost, loss or expense in connection wherewith
arising from or any person or any damage to or destruction of any property resulting from or claim to result from or arise out of accident or occurrence during or in connection with said use, including specifically such as may arise out of our be claim to arise out of
negligence on the part of said Hammerking Productions Inc., its individuals, officers, agents, sponsors, co-sponsors, sanctioners, co
-sanctioners, servants and employees.
This Waiver and Indemnification and Release is given and this agreement is made in consideration and as a condition permitting the undersigned to use course or circuit facilities or act as an official or spectator or participants or to be present in any other
capacity whatsoever at said event. I have read the foregoing Waiver,
Indemnification and Release and fully understand that no officer or agent or employee of Hammerking Productions Inc., is authorized to vary the terms or provisions of this instrument or to make any representations contrary to the provisions hereof.
“I declare that the driver or co-drivers listed on this entry application possesses the standard of competence necessary and
is physically fit for an event of this type for which this entry relates and that the vehicle entered is road worthy and suitable
for this event.” I agree to meet the requirements of Hammerking Productions Inc regarding media day, and will make myself
and team if required available for pre race and post race interviews.
I HAVE READ AND FULLY UNDERSTAND THIS ENTRY AND
RELEASE FORM AND THE CONTENTS THERETO.
I HAVE READ AND FULLY UNDERSTAND THIS ENTRY AND
RELEASE FORM AND THE CONTENTS THERETO.
Driver of Record Signature
Co-Driver #1 Signature
Date;
Date;
I HAVE READ AND FULLY UNDERSTAND THIS ENTRY AND
RELEASE FORM AND THE CONTENTS THERETO.
I HAVE READ AND FULLY UNDERSTAND THIS ENTRY AND
RELEASE FORM AND THE CONTENTS THERETO.
Co-Driver #2 Signature
Co-Driver #3 Signature
Date;
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Date;
I acknowledge that myself, my likeness, or my race/support vehicle appeared or shall appear in certain
video footage (the "Footage") which is intended to be used in conjunction with the projects now known as
King Of The Hammers 2013, King of the Hammers, King of the Hammers 4 Wheel parts last Chance Qualifier, and related Ultra4 racing projects (collectively or separately known as the “Project”), produced by King
Of The Hammers, Hammerking Productions Inc., Pinned, Eight East Inc., Heavy Metal Concepts, and all
their licensees, successors and assigns, (the “Company”) photographic, or motion picture for televised
broadcast, theatrical release, marketing campaigns, magazine, or newspaper coverage, and/or inclusion
on DVDs, VHS, downloads and streaming through websites and/or the internet in motion picture or still photography.
I acknowledge and agree as follows: Company shall have the exclusive right, throughout the universe, in
perpetuity, free of charge, to embody the Footage in any video/film, any and all audio-visual devices and
other derivatives and reproductions thereof, and any and all related
advertising and promotional materials (collectively the "Film"), and to copyright, exhibit, broadcast, distribute, sell, rent, and otherwise use and exploit the Film by any and all means, in any medium or form,
whether now or hereafter known, either alone or coupled with other
materials. Company shall have the right (but not the obligation) throughout the universe, in perpetuity, to
use my name and likeness in connection with any use or exploitation of the film
I warrant and represent that I have the right to grant the rights granted hereunder, and I shall
indemnify you for any damages incurred as a result of any breach of my warranties, representations and
agreements hereunder. The undersigned acknowledges that it has read and understands the foregoing,
and that upon signing its name below, this document shall become legally binding.
I HAVE READ AND FULLY UNDERSTAND THIS ENTRY AND RELEASE FORM AND THE CONTENTS THERETO .
Driver of record Signature
Date;
Print name
I HAVE READ AND FULLY UNDERSTAND THIS ENTRY AND RELEASE FORM AND THE CONTENTS THERETO .
Co– Driver Signature
Date;
Print name
I HAVE READ AND FULLY UNDERSTAND THIS ENTRY AND RELEASE FORM AND THE
CONTENTS THERETO.
I HAVE READ AND FULLY UNDERSTAND THIS ENTRY AND RELEASE FORM AND THE
CONTENTS THERETO.
Pit-Crew Signature
Pit-Crew Signature
Date;
Print name
Date;
Print name
I HAVE READ AND FULLY UNDERSTAND THIS ENTRY AND RELEASE FORM AND THE
CONTENTS THERETO.
I HAVE READ AND FULLY UNDERSTAND THIS ENTRY AND RELEASE FORM AND THE
CONTENTS THERETO.
Pit-Crew Signature
Pit-Crew Signature
Date;
Print name
Date;
Print name
I HAVE READ AND FULLY UNDERSTAND THIS ENTRY AND RELEASE FORM AND THE
CONTENTS THERETO.
I HAVE READ AND FULLY UNDERSTAND THIS ENTRY AND RELEASE FORM AND THE
CONTENTS THERETO.
Pit-Crew Signature
Pit-Crew Signature
Date;
Print name
Date;
Print name
I HAVE READ AND FULLY UNDERSTAND THIS ENTRY AND RELEASE FORM AND THE
CONTENTS THERETO.
I HAVE READ AND FULLY UNDERSTAND THIS ENTRY AND RELEASE FORM AND THE
CONTENTS THERETO.
Pit-Crew Signature
Pit-Crew Signature
Date;
Print name
Date;
Print name
I HAVE READ AND FULLY UNDERSTAND THIS ENTRY AND RELEASE FORM AND THE
CONTENTS THERETO.
I HAVE READ AND FULLY UNDERSTAND THIS ENTRY AND RELEASE FORM AND THE
CONTENTS THERETO.
Pit-Crew Signature
Pit-Crew Signature
Date;
Print name
4
Date;
Print name
Please make checks payable to; Hammerking Productions Inc.
Mail to;
Hammerking Productions Inc.
1040 Mt. Vernon Ave. , Suite G-309
Colton, CA 92324
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2013 4Wheel Parts Last Chance Qualifier 9/15-10/15 $400 $_____
2013 4Wheel Parts Last Chance Qualifier 10/16-11/15 $450 $_____
2013 4Wheel Parts Last Chance Qualifier 11/16-12/15 $600 $_____
2013 Ultra4 racing Membership fee (if qualified)
Onsite
2013 Griffin King of the Hammers Entry fee (if qualified)
Onsite
IRC Entry Fee (if qualified)
Onsite
Entry into the 2013 4WP LCQ is limited to the first 60 teams in order they are received. Hammerking will not accept
phone calls as place holders into LCQ. Hammerking Productions is not responsible for lost or stolen checks. Entry
fees are non refundable. Entry invitation is non transferable. Teams that advance to the main event will need to pay
balance of fees directly following the LCQ winners announcement. ( Cash Only) Ultra4 Membership is for the calendar year of 2013, and non refundable. Ultra4 membership is applicable at all Ultra4 racing sanctioned events. Additional memberships may be required at selected events in the 2013 schedule.
Winners Purse may vary at each Ultra4 racing event.
Advancing teams will be able to credit $200 towards the 2013 King of the Hammers race entry fee. Cash only. Payable following the announcement of LCQ qualified teams. The 4Wheel Parts Last Chance Qualifying guarantees at
least 10 teams will advance to the 2013 Griffin King of The Hammers. Should the total number of registered KOH
drivers not exceed 100 drivers, it is possible for additional LCQ participants to qualify. However, should the maximum
number of registered drivers meet or exceed 100 drivers no more than 10 LCQ participants will advance. Any driver
who pays an LCQ registration who qualifies at any of the remaining 2012 qualifiers will have their entire LCQ entry
fee applied towards their 2013 King of the Hammers entry fee.
Pit tent rental, and additional race related
information to follow. Please visit ultra4racing.com for more information. Teams will be
required to check in to Hammerking onsite to
receive the course map. GPS downloads will
require a team supplied SD card 2 GB or
I HAVE READ AND FULLY UNDERSTAND THIS ENTRY AND RELEASE
FORM AND THE CONTENTS THERETO.
Driver of Record Signature
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Date;