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Jesup, GA - Entry Blank
October 31 - November 1
Registration Deadline: Tuesday, October 27
Each person must have their own registration form. If you need to register for multiple people please click the link to submit another entry once you have submitted the first one.
Entrant Information
APBA Member #*

First Name:*

Last Name:*

Email:*

Date of Birth*

MM/DD/YYYY
Age*

Is this person a minor?*
Yes
No

Is the driver 16 or under?*
Yes
No

APBA Member and Club Card- Image Upload
 
Please include both cards
Club Affliliation*

Address Line 1:*

Address Line 2:

City:*

State:*

Zip Code:*

Emergency Contact Information
In Case of Emergency Contact:*

Phone Number*

At Race Site?*
Yes
No

If no, where?

Safety Information
Helmet Mfg.*


Full Face
Open Face

Life Jacket Mfg.*


Other
Capsule Jacket

Allergies*

Type "N/A" if you have none
CLASS REGISTRATION
Class Information TOTAL:
How many of the following classes will the driver be racing? JH, JR, AXH, AXR, KPH - Coupon Code will appear before Grand Total*
0 1 2 3 4 5 

Code is case sensitive
Category*
 T
Class*

ex. CSH, 125ccR, 200ccMH
Boat #*

Boat Name

Hull Make

Motor Make

Cu.In. Disp.

Prototype/Probationary?
No
Yes

Would you like to register for another class?
Yes
No

Category*
T
Class*

ex. CSH, 125ccR, 200ccMH
Boat #*

Boat Name

Hull Make

Motor Make

Cu.In. Disp.

Prototype/Probationary?
No
Yes

Would you like to register for another class?
Yes
No

Category
T
Class*

ex. CSH, 125ccR, 200ccMH
Boat #

Boat Name

Hull Make

Motor Make

Cu.In. Disp.

Prototype/Probationary?
No
Yes

Would you like to register for another class?
Yes
No

Category
T
Class*

ex. CSH, 125ccR, 200ccMH
Boat #

Boat Name

Hull Make

Motor Make

Cu.In. Disp.

Prototype/Probationary?
No
Yes

Would you like to register for another class?
Yes
No

Category
T
Class*

ex. CSH, 125ccR, 200ccMH
Boat #

Boat Name

Hull Make

Motor Make

Cu.In. Disp.

Prototype/Probationary?
No
Yes

Would you like to register for another class?
Yes
No

Category*
T
Class*

ex. CSH, 125ccR, 200ccMH
Boat #

Boat Name

Hull Make

Motor Make

Cu.In. Disp.

Prototype/Probationary?
No
Yes

Would you like to register for another class?
Yes
No

Category
T
Class*

ex. CSH, 125ccR, 200ccMH
Boat #

Boat Name

Hull Make

Motor Make

Cu.In. Disp.

Prototype/Probationary?
No
Yes

Would you like to register for another class?
Yes
No

Category
T
Class*

ex. CSH, 125ccR, 200ccMH
Boat #

Boat Name

Hull Make

Motor Make

Cu.In. Disp.

Prototype/Probationary?
No
Yes

Would you like to register for another class?
Yes
No

Category
T
Class*

ex. CSH, 125ccR, 200ccMH
Boat #

Boat Name

Hull Make

Motor Make

Cu.In. Disp.

Prototype/Probationary?
No
Yes

Would you like to register for another class?
Yes
No

Category
T
Class*

ex. CSH, 125ccR, 200ccMH
Boat #

Boat Name

Hull Make

Motor Make

Cu.In. Disp.

Prototype/Probationary?
No
Yes

AGREEMENT OF RELEASE
Release and Waiver of Liability
I acknowledge reading and agree to the terms of the Release and Waiver of Liability*

I represent by my signature below that my Agreement of Release is on file with my current membership, and my membership card number is as shown.
I further represent, if I do not possess a current membership card, that I have signed the current Agreement of Release attached with my membership application previously mailed to National Headquarters, or submitted to Registration Officials at the above regatta.
In consideration of their promotional efforts on behalf of the sport, I hereby assign all commercial communication and broadcast rights to the American Power Boat Association and do declare them as my lawful agents and representatives regarding such rights.
I, the undersigned member participating in events sanctioned by APBA, agree that APBA and its assigns may use my name and picture and pictures of my race boat, or any of them, in any way, medium, or material for promoting, advertising, recording or reporting any APBA sanctioned event before, during and after such event and do hereby relinquish all rights hereto for these purposes.
Minor Releases must be completed at race site with a legal guardian.
Entry will not be accepted unless properly signed.
Entrant Signature:*

Dated*

Parent/Guardian if under 18*

Dated*

Testing
Would you like to add tesing?
 T
Total
Sub-Total:
ENTER COUPON CODE - 16U1
ENTER COUPON CODE - 16U2
ENTER COUPON CODE - 16U3
ENTER COUPON CODE - 16U4
ENTER COUPON CODE - 16U5
16 and under J, AX, KPH discount
Card Processing Fee (3.50%):
Grand Total:
YOU MUST PAY AT RACE SITE
Credit/Debit Card Information
Would you like to pay now or at the race site?*
PAY NOW
PAY AT RACE SITE

First Name:*

Last Name:*

Card Brand:

Card Number:*

No dashes or spaces please
Expiration Month:*

Expiration Year:*

Address Line 1:

Address Line 2:

City:

State:

Zip Code:*

Please allow time for your entry to upload once hitting submit.
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