The Southern Grudge Match Association in conjunction with
 The Jefferson County Fair Association Inc.
 Demolition Derby Entry Form.
(Adult)

Please Print Car #__________

Name:___________________________________________________________

 Address:__________________________________________________________

City: _________________________ State: _______ Zip:_____________________
Phone Number:__________________________

Night Participating: Friday __________ Saturday ___________.

 I, _______________________ understand that I am not considered an employee of or a (Printed Name)                           volunteer for The Southern Grudge Match Association
and or The Jefferson County Fair Association Inc. I agree and accept that I am responsible for my own medical and accidental insurance. I agree not to hold The Southern Grudge Match Association and or The Jefferson County Fair Association Inc. or any of its
officers, directors and other volunteers liable for any accident, injury or damage to driver, driver’s assistant(s) or cars which may occur. This includes but is not limited to the arena and pit areas.

By my signature below I agree to abide by this statement & the release of any photos taken.
Signature of participant: _____________________________________________.

Pit Crew: ___________________________ ______________________________  

                ___________________________ ______________________________

Signature of notary: _________________________________________________ __________________________________________________________________