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Las Vegas Kart Club

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					                 Las Vegas Kart Club
                        Membership Application
                                   Mail application to:
                                   5841 E. Charleston
                                      Suite 230-262
                                  Las Vegas, NV 89142

____ New Membership $50.00 / 1 year                     ____ Renewal $50.00 / 1 year
____ Update Membership Information                       ____ Pit Space $50.00 / 1 year
                                                       Current pit space number ____
Members or Non-Members under the age of 18 must have a Minor Release Form Signed by a
Parent or Legal Guardian. To become a Member they are also Required to be Sponsored by a
Parent or Guardian that is either a regular member or non-racing member.

LVKC Members Name: _________________________Age ____Birth Date___/___/___
Address: ________________________________________________________________
City / State: _____________________________________________________________
Home Phone: ______________Work Phone: ___________Cell Phone: ______________
E-Mail Address: __________________________________________________________
Occupation: _____________________________________________________________
Health Insurance Provider: _________________________________________________
Additional Family Non-Racer Membership ($20.00 each). Must be at least 5 years of age
or older. Family Members are a LVKC Members Spouse, Son, Daughter, Father, Mother,
Brother and/or Sister.
Name: _____________________Relationship: __________Age: ____Birth date: ______
Name: _____________________Relationship: __________Age: ____Birth date: ______
Name: _____________________Relationship: __________Age: ____Birth date: ______
Name: _____________________Relationship: __________Age: ____Birth date: ______
Name: _____________________Relationship: __________Age: ____Birth date: ______
All Checks payable to LVKC                           Total Amount Due: $_____________
Agreement: (Must be Signed and Dated.) If accepted as a Member by the Las Vegas Kart
Club, I (and including my immediate family i.e. spouse, son, daughter, father, mother,
brother and/or sister) agree to abide by the by-laws and regulations of the club. I
represent that all statements made on this application are true to the best of my
knowledge.

Signature: ________________________________________Date: __________________

				
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posted:10/28/2011
language:English
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