2025 Frostburg Elks Derby Day
Driver Registration: Deadline is June 1, 2025
Driver Information:
Driver’s Name: ____________________________________________________________
Driver’s Mailing Address: ______________________________________________________
Driver’s Phone Number: _________________ Driver’s Weight: ______________
Driver’s Age on Race Day: ___________________ Driver’s DOB : ________________
Driver’s Grade and School: __________________________________________________
Driver’s T-Shirt Size (Please specify Child or Adult. Sizes run small): ___________________________________
Pit Chiefs Information
Pit Chief’s Name: ____________________________________________________________
Pit Chief’s Mailing Address: ___________________________________________________
Pit Chief’s Phone Number: ___________________________________________________
Pit Chief’s Email Address: ____________________________________________________
Sponsor Information
Business/Organization Name: ________________________________________________
Legal Stuff
I give my consent as guardian for the named driver to participate in Frostburg Elks Lodge #470 Derby Day and all its related activities. I release the Frostburg Elks Lodge #470, its membership, sponsors, the Frostburg City government, and any other agency or person aiding Frostburg Elks Lodge #470 from all liability relating to my child’s participation in any event leading up to and including race day. I understand and agree that all wheels must be returned to the Derby Day Committee, or I will be billed $100.00 per set. I also understand that all Derby cars owned by the Frostburg Elks Lodge #470 must be returned to the
Derby Day Committee at the end of the race. Driver’s name, image, and/or likeness may be used by Frostburg Elks Lodge #470 for promotion including pictures and video.
Driver/car must complete an inspection and 2 successful trial runs and weigh-in. The driver and their Pit Chief must attend a safety/information session.
Driver must have an official photo taken at the weigh-in.
By signing this form, I certify that all information is true and accurate and that the legal terms have been accepted.
Drivers Printed Name: _________________________________ Drivers Signature: _________________________________ __________________________________________________________ Date: ______
Drivers Guardian Printed Name; ____________________________________________ Drivers Guardian Signature: ________________________________________________ Date:
Return form to:
Frostburg Elks Lodge #470 Attn: Derby Day
126 East Main Street Frostburg, Maryland 21532
Contacts:
Jim Meyers 240-580-0968 Sharon Kyle 240-362-8029