Driver Membership Application

Driver Details

Attention

Driver membership will only be granted to drivers that hold a current Speedway Australia racing insurance card within the nominated racing division. Single gate entry per racing membership.

Name *

First

Middle

Last

Email Address

Contact Number *

Billing Address *

Address Line 1 *

Address Line 2

City *

State *

Zip Code *

Country *

Insurance Card Number

Ambulance No.

Nominated Division

Attention

The Broome Speedway Club ensures that ambulance cover is available on our premises during race meetings for all patrons/insured persons. If transport from our track is required, this becomes the responsibility of the patron/insured person.

Race No

Car Make/Model

Acceptance

I hereby apply for Broome Speedway Club Driver Membership. I undertake to be bound by the provisions of the Broome Speedway Club Rules and Regulations.

Signature Field

Clear

Junior Driver Consent

I hereby give my consent to compete in the sport of speedway racing. I understand that for my child to race at speedway a parent/guardian must be present at each race meet in the pit area. NO PARENT/GUARDIAN PRESENT and the Junior Driver will not be permitted to race that night

Parent / Guardian

First

Last

Signature Field

Clear

Product

Driver Membership

Junior - $25.00 Senior - $50.00

Total

$ 0

Additional Requests

I have read and agree to the Terms and Conditions and Privacy Policy