Racer Assistance Form

If you or someone you know is in need of assistance, please complete this form to contact us.

To receive assistance, a recipient must meet the following qualifications:

The individual must have suffered a serious injury or illness that keeps him or her from working at least 10 consecutive days.
The immediate family of a driver, crew member, or official involved in dirt track racing who are dealing with injury, illness, or death-related expenses.

PERSON NEEDING ASSISTANCE

Name(Required)

Address(Required)

Phone(Required)

Email(Required)

Home Track(Required)

Home Track City(Required)

Home Track State(Required)

Connection(Required)

REASON FOR REQUESTING QUALIFIED ASSISTANCE
If this request is related to an injury, please include information on when and where the injury happened and the individual's current condition. If request is illness related, please provide details.

SECONDARY CONTACT/PERSON REQUESTING ASSISTANCE FOR THE ABOVE

Name(Required)

Address

Phone(Required)

Email(Required)

What's Your Relation to the Individual Requesting?(Required)

"*" indicates required field

If you are chosen to be a recipient we will request frequent updates. This allows us to share your story and keep the racing community informed on the status of our recipients. Your participation will make a difference in raising future donations to help racing families heal.

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Comments

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RACER ASSISTANCE FORM

PERSON NEEDING ASSISTANCE

SECONDARY CONTACT/PERSON REQUESTING ASSISTANCE FOR THE ABOVE

MAYSON SEEMANN

Kyler Fetters

Bobbi Beach

Tammy Shearer

Naomi King

Stephanie Morgan