2ND ANNUAL CLIBURN PERFORMANCE DRIVING SCHOOL REGISTRATION FORM
(PRINT AND MAIL OR FAX THIS FORM)

NAME: _______________________________________________________________________

ADDRESS: ____________________________________________________________________

CITY: ________________________________ STATE: ___________ ZIP: _________________

AGE: _______________________ DATE OF BIRTH: _________________________________

PHONE NUMBER: _________________________ WORK PHONE: _____________________

OCCUPATION: ________________________________________________________________

NUMBER OF YEARS COMPLETED EDUCATION: _________________________________

HAVE YOU EVER DRIVEN A RACE CAR BEFORE? ________ YES _________ NO

GENERAL HEALTH ______________ GOOD ______________FAIR ____________ POOR

HEIGHT _______________________________ WEIGHT ______________________________

DO YOU HAVE ANY PHYSICAL LIMITATIONS THAT WOULD OR COULD AFFECT YOUR
PARTICIPATION IN THIS SCHOOL? ____________ IF YES, PLEASE EXPLAIN:
______________________________________________________________________________

HOW DID YOU HEAR ABOUT US: _______________________________________________

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CREDIT CARD INFO: (VISA, MasterCard, Discover, and American Express Accepted)
NAME ON CARD: _____________________________________________________________

BILLING ADDRESS: ___________________________________________________________

CREDIT CARD NUMBER: __________________________________ EXP. DATE: ________

AMOUNT CHARGED: __________________________________________________________

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Upon signing this registration form, I fully understand the details outlined on
www.teamgrt.com/cliburnschool.html and agree to the following:

1. The registration fee is non-refundable. In the event of inclement weather or mechanical failure
of the car, I will be rescheduled for another school. Cliburn Performance Driving School is not
responsible for my travel or living expenses to return for another school.
2. I will be required to sign a standard insurance release form on the day of the school before
school begins.
3. I fully understand that non-prescribed drugs and/or alcohol will not be allowed by Cliburn
Performance Driving School before or during the actual school.

SIGNATURE: ___________________________________________________________________
DATE: ______________________________________

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YOU MAY FAX THIS FORM TO 601-845-3223 OR MAIL TO:
Cliburn Performance
P.O. Box 417
Star, MS 39167

SHOP: 601-845-1360
CELL: 601-720-2848
FAX: 601-845-3223