2015 INDYCAR DRIVER S LICENSE AND MEMBERSHIP APPLICATION (FOR USE WITH NON EMANCIPATED MINOR APPLICANTS)

Transcription

1 2015 INDYCAR DRIVER S LICENSE AND MEMBERSHIP APPLICATION (FOR USE WITH NON EMANCIPATED MINOR APPLICANTS) THIS 2015 DRIVER S LICENSE AND MEMBERSHIP APPLICATION ( APPLICATION ) IS TO BE READ AND SIGNED BY EACH AND ALL PARENTS AND/OR LEGAL GUARDIANS OF MINOR BEFORE MINOR WILL BE ISSUED A DRIVER'S LICENSE AND MEMBERSHIP THAT WILL PERMIT ACCESS AND PARTICIPATION IN THE SERIES (AS DEFINED ON PAGE 6 OF THIS APPLICATION). NO PARENT OR LEGAL GUARDIAN SHOULD SIGN THE APPLICATION WITHOUT A SINCERE BELIEF THAT DOING SO IS IN MINOR'S BEST INTEREST AND WITH THE FOLLOWING UNDERSTANDING: (1) THAT THERE IS SIGNIFICANT RISK OF INJURY, INCLUDING A RISK OF PARALYSIS OR FATAL INJURY, TO MINOR DUE TO MINOR'S PARTICIPATION; (2) THAT THE RELEASE AND INDEMNITY AGREEMENT WILL PREVENT A CLAIM OR RECOVERY BY MINOR OR ON MINOR'S BEHALF, EVEN IF THE CLAIM INVOLVES THE NEGLIGENCE OF A PERSON OR ENTITY RELEASED; AND (3) THAT EACH PARENT AND/OR LEGAL GUARDIAN WILL BE PERSONALLY RESPONSIBLE FOR ANY COSTS, EXPENSES, AND/OR LIABILITY SHOULD THE RELEASE PORTIONS OF THIS APPLICATION, INCLUDING THE RELEASE AND INDEMNITY AGREEMENT AND THE MEDIA RELEASE AND ASSIGNMENT, BE VIOLATED OR MINOR'S RELEASE DETERMINED TO INVALID, EVEN IF A RELEASED AND INDEMNIFIED PARTY IS NEGLIGENT. On behalf of minor, I hereby apply to INDYCAR, LLC ( INDYCAR ) for a 2015 Driver s License and for a membership in INDYCAR for the Series. I understand that if this Application is accepted by INDYCAR, this Application, including the Release and Indemnity Agreement on page 2 of this Application and the Media Release and Assignment on page 3 of this Application, will become binding agreements between INDYCAR, minor, and me ( Agreement ). Minor and I acknowledge that we have been provided with or given access to a copy of the 2015 Series Rule Book ( Rules ), which is incorporated herein by reference and also becomes a part of the Agreement. Minor agrees to abide by the Rules, and minor understands that minor is responsible for Minor Group s awareness of the Rules and conducting themselves in accordance with these Rules. The term "Minor Group" is collectively defined as Minor Guest and each third party minor represents. Minor and I warrant and represent that we have the right to bind Minor Group as to the rights, privileges and obligations bestowed by minor s license and membership. The term Minor Guest shall mean and include any individual whose presence at an Event is at the invitation of minor. Minor and I understand that Driver s License and membership is not transferable and may be suspended or revoked by INDYCAR pursuant to the Rules. We also agree that the Agreement, including minor's Driver s License and membership, interpretation or application of the Rules, and/or interpretation or application of the Release and Indemnity Agreement and the Media Release and Assignment, is governed by Indiana law. The exclusive jurisdiction as to any action that involves the Agreement, including minor's Driver s License and membership, interpretation or application of the Rules, and/or interpretation or application of the Release and Indemnity Agreement and Media Release and Assignment, shall be a federal or state court residing in Marion County, Indiana. Minor certifies that this Application, and Agreement if approved, does not create an employment or agency relationship with INDYCAR. Minor and I acknowledge and assume all responsibility for any charges, record keeping, premiums and taxes, if any, payable on any funds minor may receive as a result of minor's activities as an INDYCAR Driver and/or Member including, but not limited to, social security taxes, unemployment insurance taxes, workers compensation insurance, income taxes and withholding taxes. Individually and on behalf of minor, I recognize the high risk of injury or death connected with minor's participation. I agree and have caused minor to understand that the only way to avoid this risk of participation is not to participate. I understand that once minor's participation begins, the risk has been undertaken and can no longer be avoided. I understand and have explained to minor that minor's injury or death, as a result of minor's participation, affects not only minor but all of minor's loved ones. Minor and I have discussed this risk with all those we think appropriate, and explained to them minor's agreement (and my agreement individually and on minor's behalf), to release minor's fellow Participants, INDYCAR, Event Promoters, and all others involved in an Event (as defined on page 2 of this Application), including a release from their own negligence (see Release on page 2 of this Application). I represent that they understand and support this decision. Minor and I understand that no one should undertake this risk without personal reflection and the input of loved ones. Minor also agrees to make Minor Group and their loved ones aware of this risk and to the extent that minor needs assistance, I will assist minor. I understand that INDYCAR is unwilling to allow minor to participate as an INDYCAR Driver and as a Member unless INDYCAR and those INDYCAR believes to be important to racing (including other participants) can have the confidence that allowing minor to participate will not result in a risk of liability for negligence of INDYCAR or specific others. I understand that my acknowledgement and assumption of risk on behalf of minor, along with the release executed individually and on behalf of minor, is intended to provide assurance of no liability. For the added legal protection and assurance that the issuance of a driver's license and membership to a minor will not result in this liability exposure, I agree to individually indemnify and hold harmless INDYCAR and each Released Party (as defined in the Release and Indemnity Agreement on page 2 of this Application) from any and all liability for damages and costs including attorney fees arising in any way from a claim or lawsuit made by minor or on minor's behalf contrary to the intent of minor's release. I agree that this indemnity obligation applies regardless of a legal determination that the minor release is in any way invalid and/or unenforceable due in any way to minor's minority, my lack of authority, or a determination of negligence as to any or all Released Parties. I understand that any injury including a fatal injury that is claimed to have been caused by wrongful conduct that is intentional or willful and wanton by a Released Party is an allegation that can have serious consequences to INDYCAR. Minor agrees not to make such a claim unless minor can support the claim by established facts and give timely notice of the claim to INDYCAR. Minor or minor s representative must deliver written notice to the President of Competition and Operations within thirty (30) days of the incident in which minor alleges the wrongful conduct occurred. The written notice must include minor's version of the incident, the factual basis of the claim, the name (identity or capacity of individual if name not known) of each person and/or entity who committed the wrongful conduct, and the nature of the injury or death caused by the wrongful conduct. Minor and I understand and agree that if minor or minor s representative fails to deliver this timely written claim to the President of Competition and Operations or fails to include the required information, minor and I agree that minor will forfeit and waive minor's or minor representative s right to define the conduct in question as anything worse than conduct that minor and I have specifically released such as negligence. Maternal Parent s Printed Name Maternal Parent s Signature Date Signed Paternal Parent s Printed Name Paternal Parent s Signature Date Signed Legal Guardian #1 Printed Name Legal Guardian #1 Signature Date Signed Legal Guardian #2 Printed Name Legal Guardian #2 Signature Date Signed Minor s Printed Name Minor s Signature Date Signed Page 1 of 6

2 RELEASE AND INDEMNITY AGREEMENT PLEASE READ CAREFULLY AND SIGN AS INDICATED In consideration of the privileges associated with a Driver s License and membership in INDYCAR for the Series (as defined on page 6 of this Application), including racing, promotional and/or entertainment or other activities associated with, sanctioned by and/or organized in cooperation with INDYCAR or occurring at the site of, contemporaneously with or reasonably connected to said activities associated with, sanctioned by and/or organized in cooperation with INDYCAR (collectively, the Event ), I agree to the following conditions on behalf of minor and for myself: 1. Assumption of Risk. Minor and I understand that minor's participation in an Event can expose minor to dangers both from known risk and unanticipated risk. Minor willingly, voluntarily and legally assumes these risks, including the risk of negligent conduct. Minor and I recognize that negligent conduct can cause property damage and personal injury, including serious injury or death. Minor and I also recognize that injuries and/or damages may be caused, increased, or compounded by negligent rescue operation or procedures. I represent that I am undertaking this risk on behalf of minor after personal reflection and input of minor and minor's loved ones. On minor s behalf, I agree to explain this risk and the need for personal reflection and input of loved ones to Minor Group. 2. Release, Covenant and Waiver. For myself, minor, and minor's heirs and assigns, I hereby release, waive, discharge and covenant not to sue INDYCAR, the Event Promoter, Track owner and/or licensee, the Federation Internationale de L Automobile ( FIA ), Automobile Competition Committee for the United States, FIA, Inc. ( ACCUS-FIA ), American Honda Motor Company, Ltd, Andersen Promotions, LLC, Bridgestone Americas Tire Operations, LLC, Cellco Partnership d/b/a Verizon Wireless, Dallara, LLC, General Motors, LLC, Honda Performance Development, Inc., Hulman Motorsports Corporation, Ilmor Engineering, Inc,, Ilmor Engineering Ltd, Indianapolis Motor Speedway, LLC, Indiana University Health, Inc., Motorsports Safety Technology, LLC, Pratt & Miller Engineering & Fabrication, Inc., Wirth Research Limited, and Participants, and their officers, directors, members, owners, successors, assigns, agents, employees, representatives, and affiliates (collectively, Released Parties ) from any and all claims or liability arising out of personal injury or property damage suffered, including, but not limited to, any claim arising out of any condition on the premises of a Track or the conduct of any person in connection with the preparation for, supervision of, or conduct of an Event, including practice, qualifications, and a Race. I am specifically releasing the Released Parties, individually and collectively, for their negligence in any form. In signing this release, I FULLY RECOGNIZE THAT IF MINOR IS HURT, SERIOUSLY OR FATALLY INJURED, HAS A LOSS AS A RESULT OF AN INJURY AND/OR MINOR'S PROPERTY IS DAMAGED WHILE ON THE PREMISES OF A TRACK OR IN REGARD TO AN EVENT, MINOR, MINOR'S REPRESENTATIVES, AND I WILL HAVE NO RIGHT TO MAKE A CLAIM OR FILE A LAWSUIT AGAINST THE RELEASED PARTIES EVEN IF THEY OR ANY OF THEM CAUSED MINOR S INJURY OR DAMAGE BY THEIR NEGLIGENCE. The term "Participants" shall include any person or entity along with their officers, directors, members, owners, successors, assigns, agents, employees, representatives, and affiliates that are in any way associated or connected with Track premises, testing facilities, or other INDYCAR approved locations or Event including but not limited to facility owners, Event Promoters, municipalities, racing associations, sanctioning organizations, Series organizers, Officials, workers, volunteers, Entrants, Car owners, Drivers, pit crew members, safety crew members, medical/rescue personnel, sponsors, manufacturers, suppliers, designers, advertisers, inspectors, construction contractors, engineers, architects, insurers, and all persons in a restricted area. 3. Indemnity. In my individual capacity and on behalf of minor, minor and I agree to indemnify and hold harmless the Released Parties as to all lawsuits, claims, damages, costs and attorneys fees, including claims as to Released Parties' sole or contributory negligence, which arise out of minor's presence and/or Minor Group s presence on the premises of a Track, minor's and/or Minor Group s involvement in an Event, and/or minor's violation and/or Minor Group s violation, including violation by either of our representatives, of any provision of this Agreement. I recognize that this indemnity applies to the unauthorized transfer or attempted transfer of credentials. As minor is releasing any claim minor's family, guardian and/or representative, including made by me and/or minor's estate, might wish to make by reason of minor's injury or death, this indemnity obligation shall specifically apply to such actions on minor's behalf and/or any such actions resulting from minor's injury or death. I also recognize that minor and I are jointly and separately responsible for Minor Group and that minor and I are legally assuring that Minor Group will not make a claim or file a lawsuit in violation of this Agreement. The terms, "Minor", "Minor Group" and "Minor Guest" are defined on page 1 of this Application. I understand that by reason of this indemnity and the indemnity agreement I personally executed on page 1 of minor's application for a Driver s License and membership, I am personally assuring the Released Parties that they individually or collectively will have no liability or damages if minor is allowed to have a Driver's License and Membership and the privileges that accompany their issuance, even if the Released Party is negligent. I acknowledge that if minor, or anyone acting on behalf of minor, makes a claim or files an action against a Released Party as defined in the Release and Indemnity Agreement, I will be responsible for the full consequences of that action and conduct, including the full indemnity as to any or all Released Parties. I UNDERSTAND THAT THIS INDEMNITY WILL APPLY EVEN IF, AND ESPECIALLY IF, THE MINOR'S RELEASE IS HELD TO BE INVALID. IN OTHER WORDS, I WILL BE ASSURING THE RELEASED PARTIES WITH NO LIABILITY, REGARDLESS OF THE LEGAL DETERMINATION AS TO MINOR'S RELEASE AND MY ABILITY TO ACCEPT RISK AND RELEASE LIABILITY ON BEHALF OF MINOR. 4. Minor Group. On behalf of minor, I recognize that minor shall require each Minor Guest to sign the applicable release(s) required by INDYCAR, Series organizer and/or Event Promoter in connection with such Minor Guest s presence and/or participation in an Event, and pursuant to the agreement to indemnify (Section 3 above), I agree that minor shall be liable for any damages resulting from a Minor Guest s failure to sign the applicable release(s) and/or abide by the terms of the applicable releases. I recognize that the indemnity agreement makes minor and me personally and fully responsible as to any member of the Minor Group, including Minor Guest. As minor and I are responsible for the conduct and claims made by Minor Group including Minor Guest against designated parties, I understand for myself and on behalf of minor the need to use care in allowing individuals and entities to become members of Minor Group, particularly individuals who are also minors in the jurisdiction in which an Event is conducted. If minor elects to include a minor in the jurisdiction in which an Event is conducted as a member of Minor Group, I understand for myself and minor that we are individually and jointly indemnifying the Released Parties for their own negligence for any claim made by or on behalf of such minor including claims that such minor s release is invalid for any reason including such minor s minority. 5. Medical Release. I understand INDYCAR must determine minor's physical and psychological fitness as a condition to issuance of a Driver s License and Membership. I understand minor must participate in a medical examination, including any drug testing requested at any time by INDYCAR, and minor agrees to do so. I understand that minor is required to notify the INDYCAR Medical Director if minor becomes aware of a change in minor's medical condition including if minor is diagnosed with any medical condition (including pregnancy) by any medical professional. I further understand that minor is required to immediately notify the INDYCAR Medical Review Officer ("MRO") at any time if minor takes, or is prescribed to take, any drugs or medication (whether or not prescription drugs or medication and regardless of how taken) and that the MRO's approval of such use in connection with an Event is required prior to minor's participation in an Event. In addition, minor agrees and consents to the Substance Abuse Policy Authorization for Testing and Release ( Authorization ) and to participate in all testing for drugs and other substances requested at any time by INDYCAR whether or not the Authorization has been formally executed and to abide by all terms included in the Substance Abuse Policy, which I hereby acknowledge I and minor have reviewed. Minor hereby waives any and all claims regarding any testing and/or testing results, including without limitation, claims of invasion of privacy and/or breach of confidentiality of information relating to such testing and testing results, notwithstanding whether such claims arise from strict liability, sole or contributory negligence, breach of contract, or any other legal theory. 6. Governing Law. It is agreed that the legal affect and validity of this Release and Indemnity Agreement is exclusively governed by the laws of the State of Indiana. Maternal Parent s Printed Name Maternal Parent s Signature Date Signed Paternal Parent s Printed Name Paternal Parent s Signature Date Signed Legal Guardian #1 Printed Name Legal Guardian #1 Signature Date Signed Legal Guardian #2 Printed Name Legal Guardian #2 Signature Date Signed Minor s Printed Name Minor s Signature Date Signed Page 2 of 6

3 MEDIA RELEASE AND ASSIGNMENT PLEASE READ CAREFULLY AND SIGN AS INDICATED I understand and agree for minor and Minor Group (as defined on page 1 of the Driver's License and Membership Application to which this Media Release and Assignment is attached), that INDYCAR, LLC ( INDYCAR ) exclusively and in perpetuity owns any and all rights to exploit any racing, promotional and/or entertainment or other activities associated with, sanctioned by and/or organized in cooperation with INDYCAR or occurring at the site of, contemporaneously with or reasonably connected to said activities (collectively, the Event ) and/or, without limiting the foregoing, Series (as defined on page 6 of this Application), or portions thereof, including without limitation the following exclusive rights: (i) all rights under copyright and otherwise to all photographic, video, audio, films, still and/or motion picture or other reproductions thereof, including without limitation all images, sounds and data (including without limitation in-car audio, in-car video, incar radio, other electronic transmissions between cars and crews and timing and scoring information), and (ii) all rights (under copyright and otherwise) in and to all radio and television broadcasts and other reproductions or depictions of any kind of any Event and/or Series or any portion thereof, including without limitation all rights in all descriptions, pictures, likenesses, images, name(s), and sound of minor or Minor Group and/or any vehicle(s) relating to minor s or Minor Group s presence and/or participation in an Event, alone or with others in any and all media whether now known or hereafter discovered, throughout the world, in perpetuity, and (iii) all rights to copyright, reproduce, distribute, display, perform, sell, license, assign, and otherwise dispose of, exploit, or turn to account any of the foregoing (or any portions thereof) alone or combined with any other materials for any purpose whatsoever, including without limitation the advertising (including without limitation by way of commercial tie-ins or co-promotions) and exploitation of any production or material incorporating any of the foregoing, together with the right to alter and/or make any and all derivative works of each (or any portion) of the foregoing. I (on behalf of minor and on behalf of Minor Group) hereby irrevocably assign to INDYCAR exclusively and in perpetuity any and all rights set forth above. I (on behalf of minor and on behalf of Minor Group) hereby grant to INDYCAR a non-exclusive, perpetual license to use, and I (on behalf of minor and on behalf of Minor Group) irrevocably consent to the use of, minor s and Minor Group's rights of publicity for the purpose of promoting an Event and/or Series or other exploitation of the rights set forth above. I represent and warrant to INDYCAR that as of the date of this assignment, I, minor and Minor Group have not granted any third party the rights described herein. Minor and I represent and agree that any and all logos, marks, designs, material or intellectual property appearing on minor s uniform or apparel or on any vehicle or equipment relating to minor s or Minor Group s presence or participation in an Event, including those of any sponsor, may be depicted in connection with the exploitation of the foregoing rights and that minor and I have obtained from all third parties the rights to assign to INDYCAR all rights assigned hereunder in connection therewith. Minor and I agree to take all steps reasonably necessary, and all other steps reasonably requested by INDYCAR, to protect, perfect or effectuate INDYCAR s ownership and other interest in the foregoing rights. Without limiting the foregoing rights of INDYCAR, I (on behalf of minor and on behalf of Minor Group) agree that INDYCAR may assign or sublicense these rights in conjunction with the commercial exploitation of an Event or otherwise, including without limitation to INDYCAR affiliates, Series organizers, a promoter of an Event ( Event Promoter ) and/or other licensees. Minor and I agree not to take any action, nor cause or permit others to take any action, nor enter into any third party agreement, which would contravene, diminish, encroach or infringe upon these rights. Further, I agree that minor and Minor Group will not reproduce, sell or otherwise use or exploit any photograph, film, video, audio, depiction or other reproduction of an Event, Event venue, INDYCAR s, Series organizer s or the Event Promoter s trademarks, name, events or other property, or assist another party in doing any of the foregoing, without INDYCAR s, Series organizer s and/or the Event Promoter s, as applicable, prior written consent. Individually and on behalf of minor, I (on behalf of minor and on behalf of Minor Group) expressly and irrevocably release and indemnify INDYCAR and its officers, directors, members, owners, successors, assigns, agents, employees, representatives, affiliates and licensees from and against any claims brought by me, minor or Minor Group, and/or minor s or Minor Group's heirs, estate, assigns and personal representatives, for invasion of privacy, defamation, misappropriation of likeness, or any other cause of action arising out of or relating to any Event or the promotion or commercial exploitation thereof or other exploitation of the rights set forth above by INDYCAR and/or its officers, directors, members, owners, successors, assigns, agents, employees, representatives, affiliates and licensees. On my behalf and on behalf of Minor Group, minor and I agree the rights granted under this Agreement are irrevocable. Minor and Minor Group shall have no right to rescind the rights nor to enjoin or restrain the distribution of the productions produced pursuant to the rights granted hereunder nor any other exploitation of any such rights. Minor and I, on our own behalf and on behalf of Minor Group, waive all rights to obtain any other equitable or injunctive relief in conjunction thereof. Maternal Parent s Printed Name Maternal Parent s Signature Date Signed Paternal Parent s Printed Name Paternal Parent s Signature Date Signed Legal Guardian #1 Printed Name Legal Guardian #1 Signature Date Signed Legal Guardian #2 Printed Name Legal Guardian #2 Signature Date Signed Minor s Printed Name Minor s Signature Date Signed Page 3 of 6

4 PARENT ACKNOWLEDGEMENT AND AGREEMENT To be completed by each and all parents of minor,. MATERNAL PARENT By signing in the space indicated below, I am, individually and on behalf of minor, executing the 2015 Driver's License and Membership Application as well as the included Release and Indemnity Agreement and the Media Release and Assignment and acknowledge and agree with each of the following statements: I am the maternal parent and natural guardian of the minor named and age. I attest that the only other natural parent, adoptive parent, or legal guardian of is/are named (listed). If the paternal parent is no longer living or no longer has parental rights, attach the legal papers to so evidence. I am signing in my capacity as parent and natural guardian of minor and understand the legal consequences to my minor child/ward. I am also signing in my individual capacity and understand that I am signing a personal release and an indemnity obligation. PATERNAL PARENT By signing in the space indicated below, I am, individually and on behalf of minor, executing the 2015 Driver s License and Membership Application as well as the included Release and Indemnity Agreement and the Media Release and Assignment and acknowledge and agree with each of the following statements: I am the paternal parent and natural guardian of the minor named and age. I attest that the only other natural parent, adoptive parent, or legal guardian of is/are named (listed). If the maternal parent is no longer living or no longer has parental rights, attach the legal papers to so evidence. I am signing in my capacity as parent and natural guardian of minor and understand the legal consequences to my minor child/ward. I am also signing in my individual capacity and understand that I am signing a personal release and an indemnity obligation. MINOR By signing in the space indicated below, I am executing the 2015 Driver's License and Membership Application as well as the included Release and Indemnity Agreement and the Media Release and Assignment and acknowledge and agree with each of the following statements: I understand that my parents and/or guardians are signing on my behalf and acknowledge and approve of each doing so on my behalf. I understand and agree to the terms and obligations of my obtaining an INDYCAR Driver's License and Membership. I attest that the names of each of my parents and guardians are: (listed) Page 4 of 6

5 LEGAL GUARDIAN ACKNOWLEDGEMENT AND AGREEMENT To be completed by each and all legal guardians of minor,. LEGAL GUARDIAN #1 By signing in the space indicated below, I am, individually and on behalf of minor, executing the 2015 Driver's License and Membership Application as well as the included Release and Indemnity Agreement and the Media Release and Assignment and acknowledge and agree with each of the following statements: I am the legal guardian of the minor named and age. Attached to this Application is the Court Order making my appointment. I attest that the only other guardians of, either legal or natural (parent) is/are named (listed). If a natural parent is no longer living or no longer has parental rights, attach the legal papers to so evidence. I am signing in my capacity as legal guardian of minor and understand the legal consequences to the minor child/my ward. I am also signing in my individual capacity and understand that I am signing a personal release and an indemnity obligation. LEGAL GUARDIAN #2 By signing in the space indicated below, I am, individually and on behalf of minor, executing the 2015 Driver s License and Membership Application as well as the included Release and Indemnity Agreement and the Media Release and Assignment and acknowledge and agree with each of the following statements: I am the legal guardian of the minor named and age. Attached to this Application is the Court Order making my appointment. I attest that the only other guardians of, either legal or natural (parent) is/are named (listed). If a natural parent is no longer living or no longer has parental rights, attach the legal papers to so evidence. I am signing in my capacity as legal guardian of minor and understand the legal consequences to the minor child/my ward. I am also signing in my individual capacity and understand that I am signing a personal release an indemnity obligation. MINOR By signing in the space indicated below, I am executing the 2015 Driver's License and Membership Application as well as the included Release and Indemnity Agreement and the Media Release and Assignment and acknowledge and agree with each of the following statements: I understand that my parents and/or guardians are signing on my behalf and acknowledge and approve of each doing so on my behalf. I understand and agree to the terms and obligations of my obtaining an INDYCAR Driver's License and Membership. I attest that the names of each of my parents and guardians are: (listed) Page 5 of 6

6 MINOR INFORMATION Please Type or Print Name: Last First Middle Name to Appear on Annual Credential: Address: Date of Birth (month/day/year): Address: Mobile Telephone Number: ( ) Provide one of the following as to Minor: Driver s License Social Security Number (Country, state and number) (last 4 digits only) Passport (country and number) Indicate previous/current FIA Driver s License History (include copy of license): Issuing Club (INDYCAR, IMSA, NASCAR, NHRA, SCCA, USAC, etc.): Grade (A, B, or C): Number: Country: Year: Series: Indy Lights Series: $1,000 Minimum age 17 (includes Indy Lights, Pro Mazda Championship, and USF2000 Championship) Pro Mazda Championship: $750 Minimum age 16 (includes Pro Mazda Championship and USF2000 Championship USF2000 Championship: $500 Minimum age: 14 with INDYCAR approval based upon driver's experience (includes USF2000 Championship only) Has minor previously been arrested for (i) an offense related to alcohol or illegal substances or (ii) a felony of any kind, which has not previously been reported in writing to the League? Yes No All Drivers must complete a 2015 Medical Authorization for Minor Driver and 2015 Substance Abuse Policy Authorization for Testing and Release. Applicant must comply with all application requirements, including without limitation providing a certified birth certificate, written resume and passing physical/psychological examinations, to be considered for a Driver s License and Membership. INDYCAR in its discretion shall determine if an Applicant is eligible to compete in any given Event. I hereby apply to INDYCAR for minor s Driver s License and Membership in INDYCAR for the Series and enclose the required fee payable to INDYCAR, LLC and two recent passport size photographs. I understand that minor s Driver s License and Membership expires on December 31, 2015, unless otherwise suspended, revoked or extended. I further understand that minor s Driver s License and Membership is the property of INDYCAR and in the event of a disciplinary action by INDYCAR or a determination by INDYCAR that minor, Minor Group and/or I have violated this Agreement or any of the Rules, including but not limited to, a determination by INDYCAR that minor and/or Minor Group have provided false, incomplete or misleading information, it must be surrendered upon demand by INDYCAR in INDYCAR s discretion. In submitting this application, I understand that I am also applying for minor s 2015 ACCUS-FIA international license and grant permission to INDYCAR to provide the information contained herein to ACCUS-FIA. I certify that the information supplied on this Application is true and correct. All 2015 Driver s License and Membership Applications must be completely filled out and accompanied by the required fee. ALL PAGES OF THIS APPLICATION, INCLUDING WITHOUT LIMITATION THE RELEASE AND INDEMNITY AGREEMENT AND THE MEDIA RELEASE AND ASSIGNMENT, MUST BE COMPLETED. Each Application requires review and approval by INDYCAR and ACCUS-FIA, and may be rejected in the discretion of INDYCAR and ACCUS-FIA. Rejection of an Application by INDYCAR may be reviewed in accordance with the Rules. Return this Application to: INDYCAR USE ONLY Date issued: Fees paid: Badge #: INDYCAR ATTN: INDYCAR Guest Relations 4790 West 16 th Street Indianapolis, IN Application Approved/INDYCAR License Verified: Competition Eligibility/Requirements: Page 6 of 6 Medical Requirements: All Applicants must forward new.jpeg photographs to credentials@indyc ar.com (applicant s name and affiliation in file name) I/