Self-Certified Safety Inspection and Waiver Forms (4-pages)
Driver Name:____________________________________________ Date:________________
Driver’s License Number & State:_________________________ Plate Number:___________
Car Make:________________ Model:_______________ Year:_______ Color:___________
Self
Helmet:
Snell SA2005 or Newer [ ]
Proper Fitting [ ]
Good Shape [ ]
Clothing:
Cotton Long Sleeves [ ]
Cotton Long Pants [ ]
Clean Shoes [ ]
Free of Cracking and Tears [ ]
Suitable: Tread Depth [ ] and Pressure [ ]
Lug Nuts Torqued to Spec. [ ]
NO: Hub/Center caps [ ] and Cracks [ ]
Tires
Balanced [ ]
Wheels
Clean [ ]
Brakes
Clean Fresh/Full Reservoir Brake Fluid [ ]
Suitable Brake Thickness: Pad [ ] and Rotors [ ]
(GPS Track Time highly recommends a brake
flush and choosing a brake fluid with high
dry and wet boiling points)
Brake Hoses Free of Cracks [ ]
Suitable Brake Pedal: Feel [ ] and Clear Path [ ]
Auto Body
Functioning:
F&R and Brake Lamps [ ]
Turn Signals [ ]
Roll Bar (open cars) [ ]
NO Loose: Bodywork/panels [ ], Bumpers [ ], Spoilers/Side Skirts [ ]
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Powertrain
Tightened: Caps [ ], Clamps [ ], and Battery Hold-Down [ ]
Belts and Hoses Free of Cracks [ ]
Suitable Fluid Levels [ ]
Suitable Clutch/Gas Pedal: Feel [ ] and Clear Path [ ]
Interior and suspension
Rear-view mirror [ ]
Appropriate headrest/restraint [ ]
No loose objects inside cabin [ ] or trunk [ ]
Seats bolted tightly [ ]
Suspension components tight w/good
bushings and ball joints [ ]
Self-Certified Safety Inspection and Waiver Form language
The technical inspection performed on my car and helmet is solely for the purpose of meeting the minimum
requirements of car preparation for this event and no representation is made by GPS Track Time, LLC, its agents,
partners, inspectors or instructors about the roadworthiness or fitness for general street driving or driving on the track
in this event. No warranties are expressed or implied in passing or failing this technical inspection, and nothing herein
creates any repair or service obligations.
In consideration of my being permitted to drive in GPS track time, LLC sanctioned auto sport events at the premises
known as Autobahn Country Club race course, in Joliet, Illinois, I release the inspectors, instructors, GPS track time, LLC
and Chan Yu from any and all liability arising from their inspection or driving whether or not it is due to their negligence.
I acknowledge at all times I am solely responsible for the safety and roadworthiness of my automobile and am not
relying on the inspection made in deciding whether or not to drive my automobile.
I certify that I am over the age of 18, that I am duly licensed to drive without restriction upon my license, that I have
proper permission and authority to use the above listed vehicle in the event, and that my liability insurance is in full
force and effect.
APPLICANT Legal Signature:______________________________________________
APPLICANT Printed Name:________________________________________________
Date:__________________________
For Official Use Only
Inspected by:________________________________
Date:______________________
Group:_____________________
Car Number:____________
Name:____________________________
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Autobahn Country Club
RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK, AND INDEMNITY AGREEMENT
IN CONSIDERATION of my being permitted to drive in GPS Track Time, LLC sanctioned auto sport EVENTS at the premises
known as Autobahn Country Club race course, in Joliet, Illinois, and participate in related on and off-track activities
(herein the "EVENTS"), or being permitted to enter for any purpose or in any capacity any RESTRICTED AREA (defined as
including, but not limited to, the driving surface, guardrails, infield pitting areas, and all walkways, concessions, and
other appurtenant areas where any activities related to the EVENTS shall take place or where any special authorization,
credentials, or permission are required to enter or where admittance to the general public is restricted or prohibited):
1. I acknowledge, agree, and represent that I have or will immediately upon entering any RESTRICTED AREA, and
will continuously thereafter, inspect the RESTRICTED AREAS which I enter, and further agree and warrant that,
my participation in any scheduled EVENTS and entrance upon any RESTRICTED AREA, constitute an
acknowledgment that I have inspected the RESTRICTED AREAS and that they are safe and reasonably suited for
the purpose of the EVENTS, and further agree that, if at any time, I am in or about a RESTRICTED AREA and I feel
anything to be unsafe, I will immediately advise track officials of such and if necessary will leave the RESTRICTED
AREA and/or refuse to participate further in the EVENTS. GPS Track Time, LLC does not make any express or
implied warranties regarding the safety, condition, merchantability or fitness of the track or facilities for any
particular purpose.
2.
I HEREBY COVENANT NOT TO SUE and RELEASE the promoters, participants, sanctioning organizations or any
subdivision thereof, track operators, officials, car owners, drivers, instructors, pit crews, rescue personnel, any
persons in any RESTRICTED AREA, sponsors, advertisers, owners, lessees of premises owners used to conducts
the EVENTS, premises and event inspectors, surveyors, underwriters, consultants and others who give
recommendations, directions, or instructions or engage in risk evaluation or loss control activities regarding the
premises or EVENTS and each of them, their directors, officers, agents and employees, all for the purposes
herein referred to as "RELEASEES", FROM ALL LIABILITY TO ME, my personal representatives, successors and
assigns, heirs, and next of kin FOR ANY AND ALL LOSS OR DAMAGE, AND ANY CLAIM OR DEMANDS THEREFOR
ON ACCOUNT OF INJURY TO MY PERSON OR PROPERTY OR RESULTING IN MY DEATH ARISING OUT OF OR
RELATED TO THE EVENTS, including my presence in or upon the RESTRICTED AREAS, or in any way competing or
for any purpose participating in the EVENTS, WHETHER CAUSED BY THE NEGLIGENCE OF THE RELEASEES OR
OTHERWISE.
3. I HEREBY AGREE TO DEFEND, INDEMNIFY, AND SAVE AND HOLD HARMLESS the RELEASEES and each of them
FROM ANY LOSS, LIABILITY, DAMAGE, OR COST they may incur due to claims brought against the RELEASEES
arising out of or related to my injury or death from the EVENTS, including my presence in or upon the
RESTRICTED AREAS, or in any way competing or for any purpose participating in the Event, WHETHER CAUSED
BY THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE.
4. I HEREBY ASSUME FULL RESPONSIBILITY FOR ANY RISK OF BODILY INJURY OR DEATH TO MYSELF, OR DAMAGE
TO MY PROPERTY due to NEGLIGENCE OF RELEASEES or otherwise, arising out of or related to the EVENTS,
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including my presence in or upon the RESTRICTED AREA, or in any way competing or for any purpose
participating in the EVENTS.
5. I HEREBY acknowledge that the ACTIVITIES OF THE EVENTS MAY BE DANGEROUS and involve the risk of serious
injury and/or death and/or property damage. I also expressly acknowledge that INJURIES RECEIVED MAY BE
COMPOUNDED OR INCREASED BY NEGLIGENT RESCUE OPERATIONS OR PROCEDURES OF THE RELEASEES.
6. I HEREBY agree that the “Release and Waiver of Liability, Assumption of Risk and Indemnity Agreement” extends
to all acts of negligence by the RELEASEES, 1NCLUDING NEGLIGENT RESCUE OPERATIONS and is intended to be
as broad and inclusive as is permitted by the laws of the State of Illinois and that if any portion thereof is held
invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.
7. I acknowledge that double sided tape will be used to temporarily affix a GPS data acquisition unit to the interior
of my car. I further acknowledge that GPS Track Time, LLC is not financially liable for any damage to my car that
may occur by the GPS unit.
8. Any physical damage done to the track or track facilities are solely the financial responsibility of the party
deemed, by the track owner or any of its agents, or GPS Track Time, LLC, to have caused the damage. GPS Track
Time, LLC is not financially liable for any damage to the track or track facilities caused by any participant of a GPS
Track Time, LLC event.
I HEREBY agree that this Agreement shall be binding upon and enforceable against me, my personal representatives,
spouse, assigns, heirs, and next of kin without limitation.
I HAVE READ THIS “RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK AND INDEMNITY AGREEMENT”, FULLY
UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND HAVE SIGNED
IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT, ASSURANCE, OR GUARANTEE BEING MADE TO ME AND
INTEND MY SIGNATURE TO BE A COMPLETE AND UNCONDITIONAL RELEASE OF ALL LIABILITY TO THE GREATEST EXTENT
ALLOWED BY LAW.
APPLICANT Legal Signature:______________________________________________
Date:__________________________
APPLICANT Printed Name:________________________________________________
Date of Birth:___________________
For Official Use Only
Date:______________________
Group:_____________________ Car Number:____________ Name:____________________________
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