QSAC ANNUAL MEMBERSHIP APPLICATION

NAME

First NameLast Name

CAR NUMBER

EMAIL ADDRESS

example@example.com

PRIMARY PHONE

Area CodePhone Number

MAILING ADDRESS

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

MEMBERSHIP*

NEW MEMBERRENEWAL MEMBER

If you are currently a QSAC member, please enter your membership number

MEMBERSHIP OPTIONS*

SINGLE EVENT LICENSE$15.00

FULL MEMBERSHIP $30.00

2nd FAMILY MEMBER$25.00

MECHANIC LICENSE$19.00

Total $0.00

Note #1: Membership fees may vary each year, with the membership period from 11/1 to 12/31 of the following year. For new members registering after 7/31, the Full Membership fees are reduced to $25.

Note #2: A mechanics license will only permit the holder to be in the “Hot Pit” area. It will not allow him/her to drive a car.

Note #3: Applications for “Full” and “2nd Family Member” Memberships received by March 31st will be eligible for the QSAC Partners drawing. The QSAC Partners Drawing is usually held prior to July 1st of the membership year.

Note #4: If you do not receive your QSAC card within 30 days after submission, please contact Doreen Brown at QSACorg@gmail.com or 517-410-3754. Please allow 30 days for all QSAC Partners Benefits to become activated.

ACKNOWLEDGEMENT AND ELECTRONIC SIGNATURE REQUIRED*

Your electronic signature below indicates you agree to follow all QSAC rules per the QSAC Rules Package. Furthermore, you understand the insurance is “Spectator Insurance” and only licensed QSAC members are allowed in the “Hot Pit” area. Violation of this rule could result in suspension of our club insurance. Your insurance is valid only when racing or practicing at a QSAC sanctioned track, and only when all racers and mechanics have a valid current year license, including those paid on the day of the event. Member agrees to waive any and all claims against the track owner(s), sponsors, and both local and national QSAC officials for injuries incurred while participating in practice & race events.

(NOTE: The QSAC Annual Membership Application MUST be signed by the actual member applying for QSAC membership. If the individual applying for a QSAC membership is under the age of 18, the parent or legal guardian of the individual applying must sign the QSAC Annual Membership Application Agreement Acknowledgement.)

SIGNATURE - PLEASE NOTE: IF USING A COMPUTER/LAPTOP OR MOUSE, PLEASE HOLD THE LEFT BUTTON WHEN YOU SIGN.*