"*" indicates required fields Name* First Last Address* Street Address City State Post Code Date of Birth* DD slash MM slash YYYY Phone*Email* ClassPrefered Club/Car NumberMembership*-Please Select-Family (2Adults and Kids U18yrs residing at home, not driving)SingleJunior under 16Life MemberHow Many Children*012345Spouse* Name Date of Birth* DD slash MM slash YYYY Child 1* Name Date of Birth 1* DD slash MM slash YYYY Child 2* Name Date of Birth 2* DD slash MM slash YYYY Child 3* Name Date of Birth 3* DD slash MM slash YYYY Child 4* Name Date of Birth 4* DD slash MM slash YYYY Child 5* Name Date of Birth 5* DD slash MM slash YYYY Do you require VSC PaperworkVSC Driver Pit Crew No VSCF Driver Pit Crew No Club Permit Rego ($30) Yes No Password* Enter Password Confirm Password Family (2Adults and Kids U18yrs residing at home, not driving) Price: Adult Price: Junior under 16 Price: Life Member Price: Credit Card American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Expiration Date Month Month010203040506070809101112 Year Year20252026202720282029203020312032203320342035203620372038203920402041204220432044 Security Code Cardholder Name
