2017 Driver Check-List

Transcription

1 2017 Driver Check-List Following you will find the necessary forms to complete your 2017 IMSA Membership/License application and Annual hard card application. This checklist is meant to assist you in completing the application(s) and ensuring that all the required information and documents are returned to IMSA. Please review the section below and check all boxes that apply to you. Return your application and remittance to IMSA, Member Services Department, One Daytona Blvd., Daytona Beach, FL or Fax to (386) Driver Membership/License Only Membership/License Application Check off Driver Check off applicable Series Sign and date where designated on Application - actual signature is required Note: Driver membership/license does not include the cost of a credential. An event credential may be purchased at registration for $ each. Driver Membership/License and Annual Hard Card Credential Membership/License Application Check off Driver Check off applicable Series Sign and date where designated on application - actual signature is required Annual Hard Card Application Check off Driver Annual Credential Competitor History Form - pages 1 and 2 (required for ALL Drivers). Competitor Physical Examination Form signed by examining physician - page 3 (required for ALL Drivers not holding a current 2017 FIA license). Medical must be dated within the last three (3) months at time of application. Authorization for Release of Medical Information (HIPPA) - (required for ALL Drivers) ImPACT Test Submission Form (mandatory for ALL Drivers competing in an IMSA sanctioned Series) Résumé of Driving Experience and copies of current license(s) - if new applicant and did not compete in a Series sanctioned by IMSA in Notarized and fully executed Release and Waiver of Liability and Indemnity Form - An original notarized copy must be received in order to receive an annual hard card via mail. FIA Driver Application (required for WeatherTech SportsCar Championship Drivers only) FIA Driver Ranking (required for WeatherTech SportsCar Championship Drivers only) - For application (made directly with the FIA) go to: Photo (Use 2016 photo) Photo Enclosed Photo via (registration@imsa.com) Fees IMSA Driver Membership/License $400 IMSA Driver Annual Hard Card Credential $500 FIA Driver License $350 FIA International Competition Letter (recommended) $150 GRAND TOTAL: Please submit to IMSA Member Services Department registration@imsa.com Page 1 of 1

2 Please type or print legibly and complete both sides of this application MEMBERSHIP/LICENSE AND ANNUAL CREDENTIAL APPLICATION & AGREEMENT ENTRANT, DRIVER & CREW First Name: Last Name: Birth Date: (see minimum age requirements in the 2017 IMSA Rules) IF UNDER THE AGE OF 19, THE APPLICANT MUST ALSO SUBMIT A FULLY EXECUTED PARENTAL CONSENT FORM Home Address: City: State: Zip Code: Country: Address: Mobile #: Business #: Team Name: Emergency Contact: Phone #: IMSA OFFICE USE ONLY Date Received Payment Type Fee Approval Code License # Date Issued Credential Number (DRIVERS Only): Hometown Driver Ranking WEATHERTECH Drivers/Entrants only: Required FIA License # Country of Residency (WeatherTech Drivers only) FIA Country of Issue IMSA SERIES (check all Series that apply) IMSA WEATHERTECH SPORTSCAR CHAMPIONSHIP IMSA CONTINENTAL TIRE SPORTSCAR CHALLENGE LAMBORGHINI SUPER TROFEO SERIES FERRARI CHALLENGE PORSCHE GT3 CUP CHALLENGE USA BY YOKOHAMA ULTRA 94 PORSCHE GT3 CUP CHALLENGE CANADA BY YOKOHAMA IMSA PROTOTYPE CHALLENGE PRESENTED BY MAZDA MEMBERSHIP/LICENSE CLASSIFICATION APPLICATION FEE ENTRANT $ DRIVER $ Approval of this application does not constitute approval to compete in the Series. New driver applicants must also submit a driver résumé before being considered for eligibility in an event. After review of the résumé, IMSA will advise applicant if they are approved and, if so, for what Series and under what conditions. CREW $ NEW MEMBER RENEWING MEMBER # ANNUAL CREDENTIAL APPLICATION THE APPLICANT MUST HAVE A VALID 2017 IMSA COMPETITION MEMBERSHIP IN THE RESPECTIVE CLASSIFICATION AND BE AN ENTRANT, DRIVER OR LISTED ON AN ENTRANT S ROSTER TO OBTAIN AN ANNUAL CREDENTIAL FORM OF ANNUAL CREDENTIAL ENTRANT ANNUAL CREDENTIAL $ DRIVER ANNUAL CREDENTIAL $ CREW ANNUAL CREDENTIAL $ FIA INTERNATIONAL LETTER $ FIA LICENSE (DRIVER OR ENTRANT) $ USE 2016 PHOTO USE ENCLOSED PHOTO PHOTO VIA (registration@imsa.com) I have included a check for the membership/license and/or annual credential application fee(s) (made payable to: IMSA) Please charge the membership/license and or annual credential fee(s) to the credit card I have on file I would like to pay by a credit card that is not on file with IMSA* *If paying by credit card, once your application is received and approved by IMSA you will receive an with a link to a secured site where you can then make payment. Approval of an application is subject to IMSA s receipt of full payment within five (5) days from the date of the . Once payment is finalized you will be ed a detailed receipt of your transaction. Page 1 of 2

3 2017 ANNUAL MEMBERSHIP/CREDENTIAL AGREEMENT I am the applicant identified above and hereby apply for an IMSA 2017 Membership/License and Annual Credential (if selected) to permit me to participate in IMSA sanctioned competition races, qualifying, testing, practices and IMSA approved promoter test days (collectively referred to as Event(s) ) for the Series selected above and in the capacity of the Membership License Classification selected above. In consideration for such rights, I agree to the following: 1. RELEASE AND WAIVER OF LIABILITY AND INDEMNITY AGREEMENT. I acknowledge that I have read, understood and voluntarily executed the 2017 IMSA RELEASE AND WAIVER OF LIABILITY AND INDEMNITY AGREEMENT as part of this Membership/License and Annual Credential Application. 2. PERSONAL INJURY AND PROPERTY DAMAGE RELEASE. I hereby release and waive any and all claims pursuant to the RELEASE AND WAIVER OF LIABILITY AND INDEMNITY AGREEMENT which I have executed as part of my IMSA Membership/License and Annual Credential Application. 3. SCOPE OF PERMISSION: I understand that an Annual Credential solely permits me to enter the track premises, the garage and the pit and pit lane area during the Events in the 2017 calendar season in accordance with the rules and procedures for access as they may be established by IMSA from time to time. IMSA may require that I carry certain identification, be accompanied by certain individuals, depart such areas, take certain actions, or refrain from taking certain actions, and I agree to abide by IMSA s directives in that regard. 4. IMSA RULE BOOK. I will make myself familiar with the current IMSA Rules, and I agree to abide by such rules as they may be amended from time to time. 5. NO TRANSFER. I understand that my Membership/License and Annual Credential (if selected) is personal to me, that I may not transfer or give it to any other person or entity, that any attempt to transfer, lend, or permit any other person or entity to use my Membership/License and/or Annual Credential may result in a fine imposed by IMSA of not less than Five Hundred Dollars ($500) and suspension or revocation of my Membership/License and/or Annual Credential. In addition, I agree to INDEMNIFY IMSA and all related parties for any damages arising in connection with such unauthorized transfer, lending, or use. 6. ADVERTISING AND PROMOTION RELEASE. IMSA, its duly authorized agents and assigns, may use, on a non-exclusive basis, my name, likeness and performance, including photographs, images and sounds of me and/or any vehicle(s) which I compete in Event(s), in any way, medium or material (including but not limited to broadcasts by and through television, cable television, radio, pay-per-view, closed circuit television, satellite signal, digital signal, film productions, audiotape productions, transmissions over the Internet, public and private online services authorized by IMSA, and sales and other commercial projects, and the like) for promoting, advertising, or reporting IMSA Events, or related telecast or programming before, during and after such Event and I do hereby relinquish to IMSA in perpetuity all rights thereto for such purpose. 7. BROADCAST AND OTHER RIGHTS. I acknowledge that IMSA exclusively and in perpetuity owns any and all rights to broadcast, transmit, film, tape, capture, overhear, photograph, collect or record by any means, process, medium or device (including but not limited to television, cable television, radio, pay-per-view, closed circuit television, satellite signal, digital signal, film productions, audiotape productions, transmissions over the Internet, public and private online services authorized by IMSA, sales and other commercial projects, and the like), whether or not currently in existence, all film, audio, video, and/or photographic, images, sounds and data (including but not limited to in-car audio, in-car video, in-car radio, other electronic transmissions between cars and crews, and timing and scoring information) arising from, during, or in connection with the Event(s) ( Work(s) ) and that IMSA is and shall be the sole owner of any and all intellectual property rights (including, but not limited to, patents, copyrights, trademarks, design rights, and other proprietary rights) worldwide in and to the Work(s) and in and to any other Work(s), copyrightable or otherwise created from the images, sounds and data arising from, during or in connection with the Event(s). In addition to the extent not already owned by IMSA, I hereby assign to IMSA exclusively and in perpetuity any and all rights set forth above. I represent and warrant that as of the date of this Agreement, I have not granted to any third party the rights described herein. I agree to take all steps reasonably necessary, and all steps requested by IMSA, to protect, perfect or effectuate IMSA s ownership or other interest in these rights. I agree not to take any action, nor cause others to take any action, nor enter into any third party agreement which would contravene, diminish, encroach or infringe upon these IMSA rights. 8. NO AGENCY OR EMPLOYEE RELATIONSHIP. I certify that I am not an agent or employee of IMSA and that I will not become an agent or employee of IMSA as a result of IMSA s approval of my application. I further certify that, with respect to any activities in which I engage in as a member of IMSA, I am either an independent contractor or an employee of another person or entity. Therefore, I assume all responsibility either by myself or my employer, for any charges, record keeping, premiums and taxes, if any, payable on any funds I may receive as a result of my activities as an IMSA member, including but not limited to, social security taxes, unemployment insurance taxes, workers compensation insurance, income taxes and withholding taxes. I understand that the receipt of this application and fee by IMSA, and/or the depositing of accompanying funds by IMSA, does not constitute approval of this application, and that all applications must be approved by IMSA Headquarters, One Daytona Blvd., Daytona Beach, Florida I warrant that all of the information provided herein is true and accurate. APPLICANT S LEGAL SIGNATURE: DATE: REMIT TO: IMSA Member Services International Motor Sports Association, LLC One Daytona Boulevard Daytona Beach, FL (USA) registration@imsa.com Page 2 of 2

4 2017 ANNUAL RELEASE AND WAIVER OF LIABILITY ASSUMPTION OF RISK AND INDEMNITY AGREEMENT THIS SECTION MUST BE CAREFULLY READ AND SIGNED BY THE APPLICANT IN CONSIDERATION OF BEING PERMITTED TO ENTER FOR ANY PURPOSE ANY RESTRICTED AREA (herein defined as including but not limited to any area requiring special authorization, credentials, or permission to enter and to which admission by the general public is restricted or prohibited), or being permitted to compete, officiate, observe, work for, or for any purpose participate in any way in the Event(s), THE UNDERSIGNED, for himself/herself, his/her personal representatives, heirs, and next of kin, acknowledges, agrees and represents that he/she has, or will immediately upon entering any of such restricted areas and will continuously thereafter, inspect such restricted areas and all portions thereof in which he/she enters and with which he/she comes in contact, and he/she does further warrant that his/her entry upon such restricted area or areas and his/her participation, if any, in the Event(s) constitutes an acknowledgement that he/she has inspected such restricted areas and that he/she finds and accepts the same as being safe and reasonably suited for the purposes of his/her use, and he/she further agrees and warrants that if, at any time, he/she is in or about restricted areas and he/she feels anything to be unsafe, he/she will refuse to participate further in the Event(s), will immediately advise the officials of such unsafe situation and will leave the restricted areas and not return. 1. HEREBY RELEASES, WAIVES, DISCHARGES AND COVENANTS NOT TO SUE THE PROMOTERS, PARTICIPANTS, RACING ASSOCIATION, SANCTIONING ORGANIZATION OR ANY SUBDIVISION THEREOF, TRACK OPERATOR, TRACK OWNER, OFFICIALS, VEHICLE OWNERS, DRIVERS, PIT CREWS, ANY PERSONS IN ANY RESTRICTED AREA, SPONSORS, ADVERTISERS, OWNERS AND LESSEES OF PREMISES USED TO CONDUCT THE EVENT(S), PREMISES OR EVENT INSPECTORS, SURVEYORS, INSURERS, UNDERWRITERS, CONSULTANTS OR OTHER PERSONS OR ENTITIES WHO GIVE RECOMMENDATIONS, DIRECTIONS, OR INSTRUCTIONS OR ENGAGE IN RISK EVALUATION OR LOSS CONTROL ACTIVITIES REGARDING THE PREMISES OR EVENT(S),THEIR PARENTS, SUBSIDIARIES, WHOLESALERS, AFFILIATED CORPORATIONS, AND EACH OF THEM, AND THE DIRECTORS, OFFICERS, AGENTS AND EMPLOYERS OF EACH OF THEM, ALL FOR THE PURPOSES HEREIN REFERRED TO AS THE RELEASEES, FROM ALL LIABILITY to the undersigned, his/her personal representatives, assigns, heirs, and next of kin for any and all loss or damage, and any claim or demands therefore on account of injury to the person or property or resulting in death of the undersigned, whether caused by the negligence of the RELEASEES, while the undersigned is in or upon the restricted area, and/or competing, officiating in, observing, working for or for any purposes participating in the Event(s). 2. HEREBY AGREES TO INDEMNIFY AND SAVE AND HOLD HARMLESS THE RELEASEES and each of them from any loss, liability, damage, or cost they may incur due to the presence of the undersigned in or upon the restricted area or in any way competing, officiating, observing, or working for, or for any purpose participating in the Event(s) and whether caused by the negligence of the RELEASEES. 3. HEREBY ASSUMES FULL RESPONSIBILITY FOR AND RISK OF BODILY INJURY, DEATH OR PROPERTY DAMAGE DUE TO THE NEGLIGENCE OF RELEASEES while in or upon the restricted area and/or while competing, officiating, observing, or working for or for any purpose participating in the Event(s). THE UNDERSIGNED also expressly acknowledges that INJURIES RECEIVED MAY BE COMPOUNDED OR INCREASED BY NEGLIGENT RESCUE OPERATIONS OR PROCEDURES OF THE RELEASEES. THE UNDERSIGNED expressly acknowledges and agrees that the activities of the Event(s) are very dangerous and involve the risk of serious injury and/or death and/or property damage and that his/her heirs and next of kin have been so advised. THE UNDERSIGNED further expressly agrees that the foregoing release, waiver, and indemnity agreement is intended to be as broad and inclusive as is permitted by law of the Province or State in which the Event(s) is conducted and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. All rights and obligations of this membership, if granted, are specific to the individual applicant executing this membership application. THE UNDERSIGNED HAS READ AND VOLUNTARILY SIGNS THE 2017 ANNUAL RELEASE AND WAIVER OF LIABILITY ASSUMPTION OF RISK AND INDEMNITY AGREEMENT, and further agrees that no oral representations, statements or inducements apart from the foregoing written agreement have been made. PRINT NAME STATE OF SIGNATURE COUNTY OF I HAVE READ THIS RELEASE The foregoing instrument was acknowledged before me this day of, 20, by, who is ( ) personally known to me; or ( ) has produced the following type of identification:. (NOTARY SEAL/STAMP) Notary Public or Signature of Witnessing IMSA Official Printed Name

5 Grade: Date Received: Amount Paid: IMSA, LLC ACCUS USE ONLY Grade: FIA License #: Fees: Instructions $350 FIA License **$150 International Competition Authorization required for event participation outside of the U.S.A. Attach one recent passport size photo and a current medical Make check payable to: International Motor Sports Association, LLC Mail to: One Daytona Blvd. Daytona Beach, FL Special Handling/scanned copy of license $50.00 Lost, stolen, upgrade or replacement license fee: $ APPLICATION FOR AN FIA DRIVER S LICENSE I, the undersigned, hereby apply for an FIA Driver s License to be issued by the Automobile Competition Committee for the United States, FIA, Inc. (Please Print or Type) Full Name: Permanent Address: Street City: State: Zip: Telephone Numbers (Home): (Office): Cell #: Fax # Date of Birth: Address Are you a U.S. citizen? Yes No If not, what country*: *If applicant is not a U.S. citizen applicant MUST obtain a permission letter from his/her home country ASN prior to submitting application. If applicant is to compete in Historic Races only, please check here If applicant is to compete in Rallies only, please check here If you have previously held an FIA Driver s License provide: Number: Year: Grade: Signature (License Holder): Date: Conditions of FIA Licenses: For entering a car, an Entrant s License is required. For driving a car, a Driver s License is required. If entrant and driver are one and the same, both an Entrant and Driver License must be held. Licenses are valid for competing in any event on the FIA Calendar, unless endorsed for Drag Racing, Historic Racing, Karting or Rallies Only. Licenses are valid for the calendar year only. Applications for renewal will be provided by the Member Clubs. If you are participating in an event outside of the U.S. please be aware of all FIA International Sporting Code regulations found on the FIA website at Additionally be aware of the Therapeutic Use Exemptions (TUE) process as outlined in Appendix A of the FIA International Sporting Code. Club Endorsement and Temporary License: Approved by: Date: This temporary license is valid for 30 days from this date. AUTOMOBILE COMPETITION COMMITTEE FOR THE U.S., FIA, INC. (ACCUS, FIA)

6 IMSA Medical Liaison Department Toni Wright Senior Medical Liaison Coordinator Office: (386) Fax: (386) Ashlee Rice IMSA Medical Administrative Assistant Office: (386) Fax: (386) Dear Driver, Please find enclosed the 2017 Driver History & Physical Examination, 2017 HIPAA Authorization for the Use and Disclosure of Health Information and ImPACT Testing Submission form. Due to applicable laws in the various states in which you may compete, IMSA requires all drivers who are 18 and under at the time of his/her initial 2017 on-track participation to sign applicable forms for MINOR competitors. If you are 18 or under, please ensure the forms provided herein are labeled for Minor Drivers and are signed by your parent(s) or legal guardian. If you have not received the correct forms based upon your age, please contact the Medical Liaison Department for the appropriate documents. It is vitally important for the safety and wellbeing of all competitors that the medical information you provide is accurate. Please thoroughly complete all sections of the History forms and sign and date in the designated location at the bottom of the form. Your personal physician should complete and sign the Physical Exam form based upon their review of your medical information and physical exam. Review and complete the top portion of the HIPAA Authorization form, initial lines A G, and sign and date the bottom. Minors are required to have all of the above forms and the Consent for Treatment of a Minor form also signed by a parent or legal guardian in the spaces provided. Finally, if not already on file, you are required to submit documentation of an ImPACT test completed within the past two years. For any drivers not racing in any IMSA sanctioned races, submission of an ImPACT test is not required. You are advised to schedule your physical examination in a timely manner and ensure that a licensed physician will be available to sign or co-sign your form (signatures of Physician Assistants or Nurse Practitioners will not be accepted). All forms must be received by the Medical Liaison Department prior to any 2017 on-track participation in any IMSA sanctioned events. Please retain a copy for your records and return all original forms to: IMSA Medical Liaison Department One Daytona Blvd. Daytona Beach, FL Do not enclose these forms with any documents sent to other IMSA departments or representatives. If you need assistance while completing your forms, please feel free to contact the Medical Liaison Department. Once these requirements have been fulfilled, your information will be applied across all IMSA-sanctioned series in which you may compete and you will not be required to duplicate this process for other IMSA series for the 2017 season. We thank you in advance for your cooperation. Sincerely, Medical Liaison Department Enclosures

7 IMSA MEDICAL FORM REQUIREMENTS FOR AGE Age 19 and Over Age 18 and Under WeatherTech, Continental Tire, Prototype Lites, GT3 Cup U.S. and Canada, Lamborghini, Ferrari Medical History form with driver signature Physical signed by physician (M.D. or D.O.) HIPAA Form, Initial A-G, signed at bottom Valid ImPACT test dated within the last two years Medical History form with driver & parental or legal guardian signatures Physical signed by physician (M.D. or D.O.) HIPAA Form, Initial A-G, with driver & parental or legal guardian signatures Consent for Treatment of a Minor form (signed by parent or legal guardian) Valid ImPACT test dated within the last two years

8 2017 IMSA Driver History and Physical Submit Original Documents DIRECTLY to the Medical Liaison s Office Pages 1 & 2 to be completed by the Driver and reviewed with Examining Physician Page 3 to be completed by Examining Physician Submission of this form with documented Physician s exam is required prior to any sanctioned on-track activity. PLEASE PRINT CLEARLY Legal Last Name Legal First Name Nick Name Age Date of Birth (Month/Day/Year) Gender Marital Status M F S M Home Address City State Zip/Country Mailing Address City State Zip/Country Home Phone Cell Phone 1 2 C EMERGENCY CONTACTS (List two) Name Relationship Home Phone Cell Phone V WeatherTech Championship Continental Tire Challenge IMSA Series & Number of Race Vehicle Prototype Lites Porsche GT3 Cup US Canada Ferrari Challenge Lamborghini Super Trofeo Team Name Entrant Garage/Shop # Name of PR Contact Cell Phone Personal Primary Care Physician Name No Current Primary Care Physician Specialty Address City State Zip/Country Office Phone Office Fax Medication: Medication: Medication: Medication: ALLERGIES Medication Allergies NONE Reactions might include symptoms such as: hives, rash and/or trouble breathing Allergies to Insects, Food, Latex, Other NONE Reactions might include symptoms such as: hives, rash and/or trouble breathing Allergy: Allergy: Allergy: Allergy: MEDICATIONS Including ALL prescription and routine Over the Counter Medications, Vitamins, Workout Supplements, Herbs, etc. NONE Name of Medication Dose Frequency/Regimen Date Started Page 1 Revised August 2016

9 2017 IMSA Driver History and Physical Last Name: First Name: Have you EVER experienced any of the following? Please respond to EACH line item, place check mark next to the appropriate diagnosis or symptom if applicable and explain any YES response in the space below. General Gastrointestinal Anemia Blood Disease YES NO Bowel Problem YES NO Anesthesia Complications YES NO Hernia YES NO Burns YES NO Liver Disease Hepatitis Cirrhosis YES NO Depression YES NO Stomach Ulcer Reflux YES NO Difficulty Sleeping Sleep Apnea YES NO Neurological High Cholesterol YES NO ADD ADHD YES NO Seasonal Allergies YES NO Concussion Head Injury YES NO Skin Problem Psoriasis Eczema YES NO Dizziness Vertigo Motion Sickness YES NO Cardiac Fainting Syncope Loss of Consciousness YES NO Angina Chest Pain Coronary Artery Disease YES NO Headaches Migraines YES NO High Blood Pressure YES NO Memory Loss YES NO Irregular Heartbeat Palpitations YES NO Seizures Epilepsy YES NO Peripheral Vascular Disease (Circulatory Problem) YES NO Stroke TIA YES NO Valve Disease Valve Replacement YES NO Orthopedic Implanted Pacemaker YES NO Amputations Prosthesis (List sites below) YES NO Automatic Implantable Cardioverter Defibrillator (AICD) YES NO Back Spine Problem YES NO Pulmonary Broken Bones (Fractures) YES NO Asthma Reactive Airway Disease YES NO Implanted Metal Plates, Pins or Screws (List sites below) YES NO Bronchitis YES NO Joint Muscle Problem YES NO Emphysema YES NO Neck Problem YES NO Endocrine Genitourinary Diabetes YES NO Kidney Bladder Urinary Problem YES NO Thyroid disorder YES NO Prostate Problem YES NO Eyes, Ears, Nose, Throat Nose Bleeds YES NO Tobacco use including smokeless tobacco YES NO Throat Problem YES NO Alcohol use YES NO Hearing Deficit Hearing Loss YES NO Recreational drugs YES NO Do you use a hearing aid? Right Left YES NO Please explain any YES responses Vision Deficit or Loss YES NO Corrective Eye Surgery (ex. Lasik, PRK) Right Left YES NO Do you use contact lenses? YES NO Do you use contact lenses while driving race vehicle? YES NO Do you use corrective glasses? YES NO Do you use corrective glasses while driving race vehicle? YES NO Any other injury, symptom or medical condition not otherwise listed: Do you use corrective sunglasses? YES NO 1. Do you use corrective sunglasses while driving race vehicle? YES NO 2. Do you wear dentures? YES NO ImPACT/Neurocognitive Testing Do you wear partial dental prosthesis? YES NO (Required for all drivers racing in IMSA sanctioned events) Date of most recent test: Social Baseline Post Injury Hospitalizations (include any/all overnight hospital admissions) NONE Date: / Reason: Date: / Reason: Date: / Reason: Prior Surgical History NONE Date: / Reason: Date: / Reason: Date: / Reason: I certify that the information I have provided herein, or that I may provide to the International Motor Sports Association LLC ( IMSA ) or its affiliates in the future, and any health care providers, is correct and complete. I further certify that I believe I am physically and psychologically fit to compete in motor vehicle racing in the 2017 IMSA season and I have no knowledge of any reason why I should not be allowed to compete. If at any time I do not personally believe that I am physically or psychologically fit to compete at any time for any reason, I will advise the IMSA Medical Liaison s Office in writing of my concern for my own fitness as soon as possible. I also certify that, should there be any change in my health status, information or medications that I will inform the Medical Liaison s Office of such change(s) as soon as practically possible, but in no event longer than five (5) business days of my discovery of such change(s). DRIVER SIGNATURE: Date: Page 2 Revised August 2016

10 2017 IMSA Driver History and Physical Last Name: First Name: PHYSICAL EXAM Date of Exam: Height: (ft) (in) Weight: (lbs) (Actual weight on date of physical exam) Vital Signs Temperature: ( F) Pulse: Rhythm: Respirations: Blood Pressure: / Most Recent Tetanus Immunization: UNKNOWN (if unknown, booster recommended) Snellen Visual Acuity Without Corrective Lenses With Corrective Lenses/Glasses LEFT EYE (OS) 20 / 20 / RIGHT EYE (OD) 20 / 20 / Binocular (OU) 20 / 20 / General Appearance = Normal Exam Body Systems Abnormal Findings Head Eyes Ears Oropharynx Neck / Thyroid Chest Heart Lungs Back Spine Abdomen Pelvis Extremities Joints Peripheral Pulses Skin Mental Status Neurological Gait The undersigned Physician has reviewed the medical history and conducted a thorough physical examination on the patient identified above. As a result of that review and examination, the undersigned Physician finds no signs, symptoms or conditions that would preclude the patient from participating in motor vehicle racing. The patient is medically cleared to compete in all motor vehicle racing activities without restrictions. Examining Physician Name (please print clearly): Physician Signature: Date: / / ***Physician Assistant or Nurse Practitioner signatures must have Physician co-signature*** ***This form will not be accepted unless signed by a Physician*** Physician s License #: State/Country: Expiration: Office Address: City: State: Zip/Country: Office Phone: ( ) Office Fax: ( ) Page 3 Revised August 2016

11 HIPAA AUTHORIZATION FOR THE USE AND DISCLOSURE OF HEALTH INFORMATION (DRIVERS / COMPETITORS) Name: Telephone:( ) Date of Birth: Address: This Authorization Form describes different uses and disclosures of health information, including as protected under state law and also protected health information as defined by the federal Health Insurance Portability and Accountability Act of 1996 ( HIPAA ) and the regulations promulgated thereunder. Unless otherwise revoked by me in writing, this Authorization expires twelve (12) months after the date of signing this Authorization ( Expiration Date ). I hereby authorize the following uses and disclosures of my Health Information, as defined below, and as permitted or required by law: (initial) A. General. I specifically authorize and direct any physician, healthcare provider, hospital or other healthcare facility who provided or is providing assessment, diagnosis, care, treatment or services to me prior to execution of this Authorization and/or any time after execution of this Authorization up to the Expiration Date, including their agents, employees and medical staff (collectively Health Care Provider ) to release my Health Information (as defined below) to (1) the IMSA Medical Liaison Department and/or their designated agents and employees (collectively Medical Liaison Department );and/or (2) NASCAR s Substance Abuse Policy s designated Medical Review Officer or its designated agent (collectively Medical Review Officer ) as requested by them for the purposes of safety, quality assurance/quality improvement, my ability or eligibility to compete, and/or my assessment, treatment or care, whether related to a medical, psychological, psychiatric, or substance abuse condition. Health Information is defined as: the full and complete medical record; hospital chart; medical history; notes; reports; data; test results; radiology reports, images and films (such as CT, MRI, and x-ray); documents related to examination or treatment for any physical or mental health condition, sickness or injury; assessments; diagnoses; prognoses; medications and prescriptions; insurance records; physician notes of patient interviews; privileged or private communications; and any and all other health information or records regarding my health or treatment, including correspondence, patient notes, and phone messages. I understand Health Information includes records disclosed to the Health Care Providers by other healthcare providers and facilities who previously provided treatment to me, and that it may include information and records protected under state law (such as certain conditions) and federal law (such as alcohol or drug abuse). (initial) B. Contagious, Infectious, or Communicable Disease. I specifically authorize and direct any Health Care Provider to release to the Medical Liaison Department to the Medical Review Officer any Health Information about me regarding assessment, diagnosis, care or treatment of a contagious, infectious or communicable disease (including, but not limited to, HIV/AIDS information, tuberculosis, measles, negative/positive diagnosis, testing, test results, status and treatment), if applicable. (initial) C. Mental Health Information. I specifically authorize and direct any Health Care Provider to release to the Medical Liaison Department to the Medical Review Officer any Health Information about me regarding assessment, diagnosis, care or treatment of a mental health condition, illness, or disease, if applicable, for the purposes of safety, quality assurance/quality improvement, my ability or eligibility to compete, and/or for my assessment, treatment or care. This Authorization does not include the release of psychotherapy notes (as that term is defined by HIPAA) recorded by a healthcare provider who is a mental health professional regarding a counseling session, but only if such notes are held separately from my medical record. This Authorization does include, for example, all information held in my medical record, other professional notes, medication prescriptions and monitoring, counseling session start and stop times, the modalities and frequencies of treatment furnished, results of clinical tests, and any summary of the following items: diagnosis, functional status, the treatment plan, symptoms, prognosis, and progress to date. (initial) D. Alcohol/Drug Abuse. I specifically authorize and direct any Health Care Provider to release to the Medical Liaison Department and/or to the Medical Review Officer any Health Information about me regarding assessment, diagnosis, care, treatment or referral regarding alcohol and/or drug abuse, if applicable, for the purposes of safety, quality assurance/quality improvement, my ability or eligibility to compete, and/or for my assessment, treatment or care. (initial) E. Discussion Permitted. I specifically authorize and direct any Health Care Provider to discuss, clarify or explain my Health Information with the Medical Liaison Department and/or the Medical Review Officer, upon their request, for the purposes of safety, quality assurance/quality improvement, my ability or eligibility to compete, and/or for my assessment, treatment or care. (initial) F. Disclosure by Medical Liaison for Certain Purposes. I authorize the Medical Liaison Department to use and disclose my Health Information in their possession, including but not limited to my IMSA Driver History & Physical Forms, IMSA Incident Medical Reports, and Infield Care Center Reports, to the following: (1) physicians, health care providers, hospitals, infield care centers, and other health care facilities for purposes of my assessment, care and treatment; and/or (2) the Medical Review Officer, and outside experts, engineers, physicians or consultants retained by any of them, for purposes of safety, quality assurance/improvement, my ability or eligibility to compete, to assist in reviewing accidents and health care services, and making assessments and recommendations related to quality or safety. I understand the Medical Liaison Department coordinators and consulting physicians are not direct treatment providers; they are present at the racetracks to facilitate the sharing of information. (initial) G. Medical Review Officer Request. I acknowledge that, under the rules of IMSA s Substance Abuse Policy, the Medical Review Officer serves as an independent and impartial physician who investigates whether a laboratory non-negative test result was due to a legitimate medical explanation. I understand that under IMSA rules the Medical Review Officer may request medical information and records as part of inquiring into whether there is a legitimate medical explanation for a result. I specifically request and permit Health Care Providers and the Medical Liaison Department to disclose, discuss and explain my Health Information as necessary to respond to such a request from the Medical Review Officer. I understand that I have the right to revoke this Authorization in writing at any time by notifying, as applicable, the disclosing Healthcare Provider, Medical Liaison Department, and/or the Medical Review Officer. I understand that the revocation is only effective after it is received. I understand that any use or disclosure made prior to the revocation in reliance on this Authorization will not be affected by a subsequently received revocation. I understand that once Health Information is disclosed pursuant to this Authorization, it may be re-disclosed by the recipient, and federal or state law might not protect it. I understand a health care provider, hospital or health facility may not condition my treatment on whether this Authorization is signed. I understand that IMSA rules and policies will govern whether I may participate in any IMSA-sanctioned event if I choose to revoke this Authorization. I have read this Authorization, I understand what it says, and any questions of mine have been answered to my satisfaction. I understand that I am entitled to receive a copy of this Authorization, and I allow a photocopy to be deemed valid as a signed original. Signature: Date:

12 IMSA Medical Liaison Department Toni Wright Senior Medical Liaison Coordinator Office: (386) Fax: (386) Ashlee Rice IMSA Medical Administrative Assistant Office: (386) Fax: (386) Entrants & Drivers: IMSA requires all drivers to complete a neurocognitive baseline ImPACT test prior to any IMSA-sanctioned ontrack activity. The test must be performed within the last two years from date of membership application by a healthcare provider who is a credentialed ImPACT consultant. Please note, if your ImPACT Test expires in the middle of the season, you must complete a new test to continue racing. Drivers may complete this requirement by going to to find a provider near you. The IMSA Medical Liaison Department will accept the ImPACT Test three different ways: The 5-page ImPACT Test report that you can obtain from your credentialed ImPACT consultant The ImPACT Test Submission form accurately completed by a credentialed ImPACT consultant The ImPACT Test Confirmation that you will receive via the address you use when you take the ImPACT Test All medical forms including the ImPACT Test Submission form are available at or by contacting the IMSA Medical Liaison department. The IMSA Medical Liaison department collects & retains all ImPACT test documents. After completing the test, a physiatrist (medical physician specializing in rehabilitation medicine) will review the test for validity & accuracy. Any concerns will be reported directly to the competitor. For information and resources about concussions, visit The Center of Disease Control and Prevention website at The Medical Liaison Department is here to assist you. Please do not hesitate to contact us. Sincerely, Medical Liaison Department Enclosures

13 ImPACT TEST SUBMISSION FORM PLEASE TYPE OR PRINT Driver Name: Date of Birth: / / Age: Cell Phone: ImPACT Test Information I have attached the most recent ImPACT Test performed on OR I have chosen not to provide a copy of my ImPACT Test. It was performed by: Printed Name of Credentialed ImPACT Consultant Signature of Credentialed ImPACT Consultant Should a copy be necessary for evaluation and/or treatment, a copy will be on file and available within 24 hours per any request from a treating physician, at the following location: Name Address City State Zip ( ) Phone Weekend Contact Information Competitor Signature: Date: Date Date If you have any questions please contact the IMSA Medical Liaison Department. IMSA Medical Liaison Department One Daytona Blvd Daytona Beach, Florida Toni Wright Phone: Fax: Ashlee Rice - Phone: Fax: