Race Registration – HQMA – 9/4/2021
2021 Dixie Shootout Membership Form
2021 USAC License
Release of Waiver of Liability
2021 Points & Results
2020 Points & Results
USAC.25 HEALTH SAFETY QUESTIONNAIRE
USAC.25 HEALTH SAFETY QUESTIONNAIRE for HQMA Region Race ON 6/25/2020
The safety of our drivers, competitors and USAC.25 members remain a priority. To prevent the spread of COVID-19 and reduce the potential risk of exposure to club members, officials and competitors, please complete this simple health screening questionnaire.
REQUIRED FOR EVERYONE ATTENDING THE EVENT
USAC .25 Driver / Handler / Spectator Name
This form should be completed by anyone attending the event; club members, officials, competitors, family and friends.
USAC .25 Track Affliation
1.In the last 72 hours have you had a fever and/or taken medication for a fever?
2. In the last 7 days have you had symptoms of a lower respiratory illness (cough, difficulty breathing, etc..)?
3. In the past 14 days have you been in close contact with a person known/suspected to have COVID-19 and/or have you been diagnosed with COVID-19?
Is the current Temperature 100.1 or higher for the person you are completing this health review?
Date Health Assessment was completed
Enter the date you completed the health assessment.
Electronic Signature of Named person above or Parent/Guardian of Minor
By typing your name, you agree the answers above are correct to the best of your knowledge.
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