Brian Brooks Blue Plate Memorial Registration 10-10-26

Brian Brooks Blue Plate Memorial Registration
Address: 5056 Nameoki Rd, Pontoon Beach, IL 62040

Raceday: October 10, 2026

Time: Sign-ins - 2:00pm-3:00pm

Driver's Meeting - 3:30

Opening Ceremonies - 4:00pm

$30 per driver until 9/4 at midnight, after registration is $35.00 per driver. Registration after 9/4 you will not be a listed participant on the back of the apparel.

Questions - Contact Bobby Hinson 618-531-0354

Issues with the form - Contact Jodi Hinson 618-407-0724
Please fill-up the form below to register to the event:
Driver Information - 1
Driver's Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Red Plate or Blue Plate?
Phone Number

Area CodePhone Number
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Person

First NameLast Name
Emergency Person Phone Number

Area CodePhone Number
Relationship to Emergency Contact Person
Ask the driver -- What is your favorite thing about racing?
Driver Information - 2
Driver's Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Red Plate or Blue Plate?
Phone Number

Area CodePhone Number
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Person

First NameLast Name
Emergency Person Phone Number

Area CodePhone Number
Relationship to Emergency Contact Person
Ask the driver -- What is your favorite thing about racing?
Driver Information - 3
Driver's Name

First NameLast Name
Red Plate or Blue Plate?
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone Number

Area CodePhone Number
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Person

First NameLast Name
Emergency Person Phone Number

Area CodePhone Number
Relationship to Emergency Contact Person
Ask the driver -- What is your favorite thing about racing?
Driver Information - 4
Driver's Name

First NameLast Name
Red Plate or Blue Plate?
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone Number

Area CodePhone Number
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Person

First NameLast Name
Emergency Person Phone Number

Area CodePhone Number
Relationship to Emergency Contact Person
Ask the driver -- What is your favorite thing about racing?
Registration Charges
Registration Fee
prevnext( X )
1 Driver$30.00

2 Drivers$60.00

3 Drivers$90.00

4 Drivers$120.00

Total $0.00
Release & Agreement
I understand to be listed on the t-shirt I need to register by September 4th, 2026. If I register after 9/4/2026, I know the driver's name(s) will not be on the apparel.
Parents's Signature
Date Signed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Payment Methods

Choose from one of the PayPal options to make your payment.
Should be Empty:

Brian Brooks Blue Plate Memorial Registration

Driver Information - 1

Driver Information - 2

Driver Information - 3

Driver Information - 4

Registration Charges

Registration Fee*

Release & Agreement

Payment Methods

Registration Fee