2012 Rausch Creek Entry Form

CAR NUMBER
CLASS
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
All entries must be complete including additional requested information.
You may return entry form electronically to Shannon@Ultra4Racing.com
This is a time sensitive document.
Entry deadline is May 15th, 2012
Applications and payment must be received no later than midnight May 15th, 2012
Make checks payable to Hammerking Productions Inc. No online payments will be available for this race.
Hammerking Productions Inc
PO Box 1182 Twin Peaks, CA 92391
Notice: Ultra4 racing membership is required for participation in all 2012 Hammerking events except where noted. Yearly drivers license fee is
$100.00 Total fees due for participation in 2012 KOH $100.00 Ultra4 Membership is from Jan 1st to December 31st yearly, there is no pro-rated
entry for Ultra4 Membership.
New drivers must fill out all the fields below. For drivers who have completed a 2012 entry form, all fields in red
must be completed as do any fields that may have changed from prior races.
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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 or Driver of record head shot 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 Rausch Creek Qualifier, I am releasing Hammerking Productions Inc., Dave
Cole, and its volunteers, contractors, 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 ULTRA4 Racing or supporting races.
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 Rausch Creek Qualifier 2012 AND Supporting Races 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;
All Pit crew members must sign this form.
By completing this form, I hereby apply to Hammerking Productions Inc, to participate as a Pit crew worker in the Rausch Creek
Qualifier off-road event to be held June 1st-3rd, 2012. By my signature below, I certify that I have read, and understand, and
accept the following representations, stipulations, and waivers. I have read and understand the Rules of the event and agree to
abide by them.
I understand that Hammerking Productions Inc and/or, their lessees, agents, directors, officers, servants, employees, volunteers
and co-promoters if any, will not accept financial or legal liability for any injury, physical damage or other occurrence arising from
the event or activities of the above persons. Accordingly, my participation in such event and activities shall be at my own risk.
I understand that my operation of the motor vehicle in the event subjects me to the laws of the event State, and further, acknowledge that I must abide by all of the rules and regulations as adopted by the Event. I waive all rights to the use of my name, and
likeness of myself, or equipment for entertainment, or commercial promotional uses.
Accordingly, I forever release, discharge and waive, for myself, my personal representative, heirs, and next of kin, all claims which
I might have against Hammerking Productions Inc and/or the property owners, their agents, directors, offices, servants, volunteers or representatives, for and from any injury, accident, illness, property damage, death or other occurrences arising in any
manner whatsoever which is caused by or arises out of my participation in this event. I expressly assume all risk of my participation including the risk that I might be injured or die as a result of the negligence or gross negligence of Hammerking Productions
Inc. or others who are under their direct and indirect control.
I expressly assume financial and/or legal liability for all risks or injury to persons who accompany me to this event including my
family members, guests, friends, and acquaintances, and all other persons who accompany me in my registered vehicle. Furthermore, I agree to indemnify, save and hold harmless Hammerking Productions Inc. and/or the property owners, or their agents,
directors, officers, servants, employees, volunteers, and lessees, from all risks assumed above and any damage to personal property or personal injury caused by others.
I understand that all refueling and fuel storage will be done in accordance with the Ultra4 Racing rule book, as well as the New
Mexico Off Road League rules. No fuel shall be stored without an approved catch basin and clearly marked as fuel storage, and
posted as flammable. All pit work will be conducted over an approved pit mat. I understand that Rausch Creek Qualifier a no
chase race, and that race vehicles shall be serviced only in approved pit locations. I understand that pit roads are under a safe
speed control and that all roads may have two way traffic at any time.
BACK SIDE OF THIS WAIVER MUST BE SIGNED BY ALL RACE TEAM PIT CREW MEMBER,OR ANY OTHER
PERSONS WHO WILL PHYSICALLY PRESENT THEMSELVES ON THE EVENT TRACK WITHIN THE RESTRICTED
AREA. I UNDERSTAND THAT THE DRIVER OF RECORD IS RESPONSIBLE FOR EACH MEMBER OF HIS TEAM
AND MAY FACE PENELTIES IF HIS TEAM ACTS OUTSIDE THE RAUSCH CREEK OFFROAD PARK AND ULTRA4
RULES.
I UNDERSTAND THAT EACH TEAM PARTICIPATING IN ULTRA4 RACING EVENTS MUST PROVIDE THEIR OWN
FORM OF RECOVERY VEHICLE IN THE EVENT THE RACE CAR IS DISABLED. ULTRA4 RECOVERY CREWS ARE
FOR THE ASSISTANCE OF RACE VEHICLES DURING THE RACE TO ENSURE A SAFE RACE COURSE. I UNDERSTAND THAT ULTRA4 RECOVERY CREWS WILL PROVIDE ASSISTANCE TO DRIVERS AS A SAFETY MEASURE,
BUT ARE NOT RESPONSIBLE FOR THE RECOVERY OF RACE VEHICLES FOLLOWING THE EVENT TO THE MAIN
CAMP AREA’S. I UNDERSTAND THAT HAMMERKING PRODUCTIONS, ITS RELATED RACE MANAGEMENT ,
AND RECOVERY CREWS ARE NOT RESPONSIBLE FOR DAMAGE TO MY VEHICLE.
I HAVE READ AND FULLY UNDERSTAND THIS ENTRY AND RELEASE
FORM AND THE CONTENTS THERETO.
Driver of Record Signature
Date;
_______________________________________________________________________
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Each pit crew member must read
and sign the attached portion of
this document. Make copies as needed.
I HAVE READ AND FULLY UNDERSTAND THIS ENTRY AND RELEASE FORM AND THE CONTENTS THERETO .
Pit-Crew Signature
Date;
Print name
I HAVE READ AND FULLY UNDERSTAND THIS ENTRY AND RELEASE FORM AND THE CONTENTS THERETO .
Pit-Crew Signature
Date;
Print name
I HAVE READ AND FULLY UNDERSTAND THIS ENTRY AND RELEASE FORM AND THE CONTENTS THERETO .
Pit-Crew Signature
Date;
Print name
I HAVE READ AND FULLY UNDERSTAND THIS ENTRY AND RELEASE FORM AND THE CONTENTS THERETO .
Pit-Crew Signature
Date;
Print name
I HAVE READ AND FULLY UNDERSTAND THIS ENTRY AND RELEASE FORM AND THE CONTENTS THERETO .
Pit-Crew Signature
Date;
Print name
I HAVE READ AND FULLY UNDERSTAND THIS ENTRY AND RELEASE FORM AND THE CONTENTS THERETO .
Pit-Crew Signature
Date;
Print name
I HAVE READ AND FULLY UNDERSTAND THIS ENTRY AND RELEASE FORM AND THE CONTENTS THERETO .
Pit-Crew Signature
Date;
Print name
I HAVE READ AND FULLY UNDERSTAND THIS ENTRY AND RELEASE FORM AND THE CONTENTS THERETO .
Pit-Crew Signature
Date;
Print name
I HAVE READ AND FULLY UNDERSTAND THIS ENTRY AND RELEASE FORM AND THE CONTENTS THERETO .
Pit-Crew Signature
Date;
Print name
I HAVE READ AND FULLY UNDERSTAND THIS ENTRY AND RELEASE FORM AND THE CONTENTS THERETO .
Pit-Crew Signature
Date;
Print name
I HAVE READ AND FULLY UNDERSTAND THIS ENTRY AND RELEASE FORM AND THE CONTENTS THERETO .
Pit-Crew Signature
Date;
Print name
I HAVE READ AND FULLY UNDERSTAND THIS ENTRY AND RELEASE FORM AND THE CONTENTS THERETO .
Pit-Crew Signature
Date;
Print name
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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 Ultra4 racing projects
(collectively or separately known as the “Project”), produced by King Of The Hammers, Hammerking Productions 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
I HAVE READ AND FULLY UNDERSTAND THIS ENTRY AND RELEASE FORM AND THE
CONTENTS THERETO.
Pit-Crew Signature
Date;
I HAVE READ AND FULLY UNDERSTAND THIS ENTRY AND RELEASE FORM AND THE
CONTENTS THERETO.
Date;
I HAVE READ AND FULLY UNDERSTAND THIS ENTRY AND RELEASE FORM AND THE
CONTENTS THERETO.
Date;
Date;
Print name
I HAVE READ AND FULLY UNDERSTAND THIS ENTRY AND RELEASE FORM AND THE
CONTENTS THERETO.
Print name
Pit-Crew Signature
Pit-Crew Signature
Print name
I HAVE READ AND FULLY UNDERSTAND THIS ENTRY AND RELEASE FORM AND THE
CONTENTS THERETO.
Print name
Pit-Crew Signature
Pit-Crew Signature
Date;
Date;
Print name
I HAVE READ AND FULLY UNDERSTAND THIS ENTRY AND RELEASE FORM AND THE
CONTENTS THERETO.
Print name
Pit-Crew 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
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Date;
Print name
Please make checks payable to:
Hammerking Productions Inc.
PO Box 1182 Twin Peaks, CA 92391
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2012 Rausch Creek Qualifier fee for Ultra4 (4400)
$575 ______
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2012 Rausch Creek Qualifier for 4500 & 4600
$400 ______
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2012 Ultra4 racing Membership fee
$100 ______
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Late fee for entries paid between 5/15/12 and 5/25/12
$100 ______
Total fees paid
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All fees must be paid in full by May 15th 2012. Hammerking Productions is not responsible for lost or stolen checks,
and deadline for entries received is considered midnight May 15th 2012. Online payment is NOT available for this
race, so do not delay in mailing your forms. For additional questions concerning payment please contact Dave Cole at
909 366 8066, as soon as possible. Entry fees are non-refundable.
Ultra4 Membership is for the calendar year of 2012, and non-refundable. Ultra4 membership is applicable at all Ultra4 racing sanctioned events. Winners Purse may vary at each Ultra4 racing event. Winners purse may vary at each
Ultra4 racing event.
Rausch Creek Qualifier is the first race in the 2012 Ultra4 4WD Hardware Eastern Regional Series. Series points will
be awarded for all three races in this series including the Badlands Qualifier and the National Championship in Blackwell, TX. The 4WD Hardware Eastern Regional Series Champion will be the driver with the most points at the end of
all 3 races. Teams will be required to check in onsite to receive course map and info.
I HAVE READ AND FULLY UNDERSTAND THIS ENTRY AND RELEASE
FORM AND THE CONTENTS THERETO.
Driver of Record Signature
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Date;