Race Team Application

1. Racer Information

Legal Name(Required)

First Name Middle Name (Optional) Last Name

(No nicknames)

Address(Required)

Street Address City State ZIP Code

Contact Info

Telephone(Required)

Cellphone(Required)

Racer Email(Required)

Parent Email(Required)

Additional Info

Age(Required)

Date of Birth(Required)

Gender(Required)

Male

Female

Mother's Name(Required)

Father's Name(Required)

Age Bracket(Required)

USSA Membership Number(Required)

All Groups require membership in USSA. U 12 & up require membership in Tri State.

2. Emergency Contact Info

First Emergency Contact

Name(Required)

First Last

Home Phone(Required)

Cell Phone(Required)

Work Phone(Required)

Second Emergency Contact

Name(Required)

First Last

Home Phone(Required)

Cell Phone(Required)

Work Phone(Required)

3. Pertinent Emergency Medical Information

Family Physician

Name(Required)

First Last

Telephone(Required)

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Race Team Application

1. Racer Information

Contact Info

Additional Info

All Groups require membership in USSA. U 12 & up require membership in Tri State.

2. Emergency Contact Info

First Emergency Contact

Second Emergency Contact

3. Pertinent Emergency Medical Information

Family Physician

Jiminy Peak Mountain Resort

Jiminy Peak Mountain Resort