FMSA c/o Jesse Teed 
21103 Reindeer Rd.
Christmas, Fl 32709 2010 Membership Application
Driver/Owner: ___________________/______________________ Car #: _______
Name: __________________________________________________
Address: _______________________________________________
City, State, Zip Code: _______________________________________________
Sponsors: ______________________________________________
Chassis:_______________________________ Engine ____________________ cc
Date of Birth: _______/______/19_______ S.S.N.: _______-_____-_______
PH.#:(_______) _______-_________ EMAIL: ____________________________
Employer: _________________________ Occupation: _____________________
In Case
of Emergency
Contact: __________________________________________________
Blood Type: _________________________ Allergies:
_____________________
Injury release
I agree that when I participate in any Florida Mini Sprint Association event or function, I do so at my own risk and
that Florida Mini Sprint Association, officers, members, crew, participants or tracks are not responsible for any
bodily injury or any damage to property belonging to myself.