PIT CREW U TERMS AND HEALTH QUESTIONNAIRE

Personal Information

HIPPA CONSENT

HIPAA is the Health Insurance Portability and Accountability Act. This form summarizes important information regarding Pit Instruction and Training, LLC health care services and provides your written consent for treatment/care by Pit Instruction and Training, LLC health care providers and your consent to health care providers to use and disclose your protected health information for treatment, payment for services, and health care operations.

SERVICES OFFERED

Pit Instruction and Training, LLC may provide a variety of services related to the care, prevention and rehabilitation of injuries incurred by program participants. Physicians, licensed athletic trainers, physical therapists, massage therapists and other health care providers may provide services at Pit Instruction and Training, LLC facilities. The health care providers will determine if the care needed involves resources or competencies beyond the scope of available services, and will provide the appropriate referral, documentation, and follow-up.

CONFIDENTIALITY

Your medical records on file at Pit Instruction and Training, LLC are treated as confidential records and will only be released pursuant to your authorization or as otherwise permitted or required by law.

PARTICIPANT RESPONSIBILITIES

Program participants are expected to honestly answer the PAR-Q, Health History, and related questionnaires and provide a full and accurate medical history to the health care providers at the time of the assessment for participation in Pit Instruction and Training, LLC programs. Passing the assessment does not mean that the program participant is physically qualified to engage in activity but only that the examiner did not find a disqualifying medical condition. The program participant has a continuing responsibility to report all injuries or illnesses immediately to the Pit Instruction and Training, LLC health care providers and to follow the physicians, licensed athletic trainers, physical therapists, massage therapists and other health care providers instructions concerning the prevention, treatment, and rehabilitation of injuries.

CONSENT FOR TREATMENT/CARE

I have read the above material regarding rights and responsibilities of the program participant as it relates to Pit Instruction and Training, LLC. I understand its provisions, and agree to receive services under the above conditions and I consent to treatment/care, as determined to be necessary by the physicians, licensed athletic trainers, physical therapists, massage therapists and other health care providers.

CONSENT FOR USE AND RELEASE OF INFORMATION

I give permission to Pit Instruction and Training, LLC affiliated health care providers to release any information about me, my health, the health services provided to me, or payment for my health services which may be necessary; 1) For my treatment – to any physician, or other health care providers or facilities which need the information for my continued care; I further authorize Pit Instruction and Training, LLC health care providers and consulting physicians to hospitalize and secure treatment for me for any athletic injuries, 2) For payment purposes – to determine whether I am eligible for insurance coverage and if this treatment/care is authorized for payment by my insurance. This information may also be used to process an insurance claim, for billing and for collection purposes, 3) For Pit Instruction and Training, LLC affiliated health care providers to operate its business more efficiently, and to assess and improve the quality of its health care.

SUBSTANCE ABUSE POLICY

PURPOSE - It is the goal of Pit Instruction and Training, LLC to assure a safe work environment for its contractors and employees and provide quality service for its program participants and customers. To help Pit Instruction and Training, LLC attain these goals, a drug and alcohol-free workplace is necessary.

STATEMENT - Pit Instruction and Training, LLC policy regarding alcohol and other drugs requires compliance with the following rules:

1. The use, possession, solicitation for, or sale of, narcotics or other illegal drugs, alcohol or prescription medication without a prescription, on employer or client premises or while performing an assignment is prohibited.

2. Impairment or being under the influence of legal or illegal drugs or alcohol, on employer or client customer premises or while performing an assignment, is prohibited.

3. The use, possession, solicitation for, or sale of legal or illegal drugs or alcohol off the employer or client customer premises that adversely affects the employee’s work performance, his or her own or others safety at the workplace of the employer or client company’s reputation is prohibited.

4. The distribution or use of controlled substances or illegal drugs at company or customer sponsored functions is prohibited.

5. Having a measurable presence of any controlled substance or alcohol in the body while at work is prohibited.

USE OF CONTROLLED SUBSTANCES AS MEDICATION - Although we recognize contractors and employees may be able to report to work while taking medications prescribed by a physician, contractors and employees are expected to discuss the potential side effects of prescribed medication with the prescribing physician. Any question regarding the medication’s effect on the safe and efficient performance of assigned duties must be discussed with Pit Instruction and Training, LLC staff prior to reporting to work. Contractors and employees must keep all prescribed medicine in its original container, which identifies the drug, date of prescription and prescribing doctor.

DRUG TESTING - Some of our customers require pre-employment drug screening for all contractors and employees placed on assignment at their facility. Contractors and employees will be required to meet the pre-employment drug-screening test before placement with such a customer. Pit Instruction and Training, LLC will require an employee on assignment at a customer’s location to abide by drug or alcohol testing requirements. Pit Instruction and Training, LLC requires pre-employment drug screening for all contractors and employees placed on driving assignments. An employee may be required to submit to alcohol or controlled substances testing whenever there is reason to believe an employee is using drugs or abusing alcohol in violation of the employer’s or client customer’s controlled substances policies. Additionally, supervisor may request contractors and employees to submit to drug or alcohol testing in connection with a safety investigation, or for random testing. In the event that the Pit Instruction and Training, LLC Substance Abuse Policy is in contrast with a customer’s policy, the more stringent policy shall apply.

REASONABLE SUSPICION - The use of or being under the influence of drugs or alcohol while at work is contrary to this policy. All individuals at work who are believed by supervision to be under the influence of drugs or alcohol must submit to drug or alcohol testing upon request. Reasonable suspicion can occur when an employee’s actions, appearance or conduct are indicative of an employee under the influence of drugs or alcohol, such as erratic behavior or staggering or faltering contractors and employees who test “positive” on reasonable suspicion will be terminated from PIT Instruction & Training

TEST RESULTS - Applicants whose tests are returned positive will be given an opportunity to discuss the results with a Medical Review Officer (MRO) to rule out anything that might cause a false positive. Should an employee have a confirmed positive test result, we will be unable to place the employee on any assignment. At management’s discretion, a second screening after 30 days may be granted at the employee’s expense. Any employee testing positive on the second screening will be permanently barred from employment. Any employee who passes the second screening will then be tested for one year on an individual random basis. Any positive test of such random testing will result in discharge. - All positive test results will be confirmed in accordance with all applicable state laws.

INSUBORDINATION AND FALSIFICATION - If an employee refuses to participate in a required alcohol or drug test, or attempts to invalidate the results of the test, the employee will be discharged.

CONFIDENTIALITY - All test results will be treated confidentially and are the sole property of Pit Instruction and Training, LLC.

WHAT DRUGS ARE TESTED? - The company may test for any or all of the following drugs or classes of drugs, and their Metabolites or derivatives, including: marijuana (cannabinoids), cocaine, propoxyphene (Darvon), benzodiazepines, phencyclidine (PCP), methadone, opiates, amphetamines, barbiturates and alcohol. The company also reserves the right to test for other drugs of suspected abuse.

Sample Testing Drugs - The Company will use urine, blood, oral fluid, or any of these three, for drug testing. Alcohol - The Company will use breath, urine, blood or any of these three for alcohol testing.

SEARCHES - The company reserves the right to conduct a reasonable, unannounced search of its premises if it believes an employee may be in possession of alcohol or drugs. In special circumstances a law enforcement representative may assist the company in searching an employee and his/her possessions. Refusal to cooperate in a reasonable search will result in discharge. “Premises” means any company or client customer vehicle, office, factory, warehouse, building, shop, parking lot or property which is owned, leased, rented or operated by the company or client customer; or any other site at which an employee performs company or client customer work. “Possession” means: on an employee’s person, in an employee’s tool box, lunch box, brief case or purse; or in and area entrusted to the control of an employee such as a company or client customer vehicle, desk, file, closet or locker.

CONSENT & AUTHORIZATION - Pit Instruction and Training, LLC has customers that have adopted policies requiring pre-employment and reasonable cause drug screening. By signing your name herein below, applicant/employee is expressing a desire for consideration to be assigned to all customers and consents to undergo a drug-screening test prior to beginning work, as required. Contractor’s and employee’s agree to supply urine and/or other specimen with the understanding that part of the specimen will be used to test for the presence of illegal drugs, alcohol or controlled substances, and that the result of such test may be disclosed to Pit Instruction and Training and to the customer who requested the screening.

NASCAR SUBSTANCE ABUSE POLICY HIGHLIGHTS

1. ADMINISTRATION: NASACAR will continue to work with Sports Medicine and Research Training (SMRTL). SMRTL personnel will be responsible for all driver pre-season testing and random substance abuse tests. SMRTL is the largest independent sports and forensic certified testing laboratory in the United States.

2. BASELINE TEST: All NASCAR Cup Series, XFINITY Series and NASCAR Gander RV & Outdoors Truck Series drivers, crew members and NASCAR officials will be required to submit to a substance abuse test prior to the start of each NASCAR season.

a. NASCAR will have SMRTL personnel on site in Daytona during testing to conduct all substance abuse tests for the drivers.

b. Drivers who are new to the NASCAR Cup Series, XFINITY Series or Camping World Truck Series will be required to submit to a mandatory substance abuse test by SMRTL or NASCAR prior to competing in an event.

c. Car owners will be required to conduct internal team substance abuse testing by a Substance Abuse and Mental Health Services Administration (SAMHSA) certified laboratory and certify to NASCAR that all licensed crew members have passed such testing prior to the start of each NASCAR season.

d. NASCAR will conduct a baseline test for its officials prior to the start of each NASCAR season.

3. RANDOM TESTING: In addition to NASCAR’s long-standing reasonable suspicion clause in the substance abuse policy, all NASCAR Cup Series, XFINITY Series and Camping World Truck Series drivers, over-the-wall crew members and NASCAR officials will be subjected to random substance abuse tests throughout the season. Tests will be conducted at most, if not all events. Names will be randomly generated through a computer program by SMRTL. Random tests will be conducted by SMRTL personnel with the assistance of NASCAR. NASCAR will work within the boundaries of each track’s existing schedule requirements for the drivers, over-the-wall crew members and officials to select a time to conduct these tests. The tests will not be optional. A failure to appear for a test after being selected will result in a failed test.

4. OVER-THE-WALL CREW ROSTER: Teams will be required to submit an annual roster of over-the-wall crew members to NASCAR prior to the start of each NASCAR season. Any changes to the over-the-wall crew member roster must be submitted and approved by NASCAR. Changes should be submitted to each respective Series Director.

5. PENALTIES: NASCAR’s long-stated penalties for violations will remain in place. Violations of the Substance Abuse Policy will result in an immediate suspension from competition. Any Competitor violating the policy will have to meet detailed criteria prescribed by NASCAR’s outside experts in order to be considered for reinstatement. While it is possible that a competitor could receive a lifetime ban for just one violation, a third violation of that policy will automatically result in a lifetime ban.

6. EFFECTIVE DATE: This policy will go into effect at the start of each NASCAR season.

CONFIDENTIALITY AGREEMENT

I hereby acknowledge and agree that, from time to time, I may receive information from or regarding Performance Instruction and Training, LLC in the nature of trade secrets or that otherwise is confidential, the release of which may be damaging to Performance Instruction and Training, LLC or Persons with which it does business. I agree that I shall hold in strict confidence any information I receive regarding Performance Instruction and Training, LLC as being confidential and may not disclose it to any person or entity other than a member of Performance Instruction and Training, LLC, except for disclosures compelled by law (but I agree to notify Performance Instruction and Training, LLC promptly of any request for that information before disclosing it) or of information received from a source independent of Performance Instruction and Training, LLC that was obtained without breach of confidentiality. I hereby acknowledge and agree to hold such in confidence until Performance Instruction and Training, LLC states otherwise in writing. I hereby acknowledge and agree that breach of this agreement may cause irreparable harm and injury to Performance Instruction and Training, LLC for which monetary damages may be inadequate, difficult to compute, or both. I further acknowledge and agree that this agreement may be enforced by specific performance. I hereby acknowledge and agree that I have read this agreement and fully understand and agree to be bound by its contents.

CONTRACTOR AGREEMENT

I understand and agree that from time to time Pit Instruction and Training, LLC will secure or attempt to secure work on my behalf either through contracts with clients or for various events and programs presented at or by Pit Instruction and Training, LLC. I also agree and understand that any work either for Pit Instruction and Training, LLC or secured by Pit Instruction and Training, LLC on my behalf is on a contractual basis and does not imply or express in any manner employment by or with Pit Instruction and Training, LLC or any of its clients or affiliates either currently or in the future. In consideration of this service, I agree that I will maintain a current facility membership account in good standing and remain available for placement by Pit Instruction and Training, LLC for the length of six (6) months from the date of this agreement or the duration of any and all race series license purchased by Pit Instruction and Training, LLC on my behalf. Should I fail to maintain an account in good standing or make myself unavailable for placement by Pit Instruction and Training, LLC, I understand that a fee of $500.00 will become immediately due in addition to any other outstanding balances that I owe Pit Instruction and Training, LLC, including facility membership fees, equipment fees, and race series licenses purchased on my behalf.

PHYSICAL READINESS TEST

You are required to participate in a series of physical assessments on your first two nights of class. A list of those physical activities will be emailed to you for your review upon submission of your application.

Passing a one-mile test performed in 15 minutes or less is a required in order to be admitted to the program.

Declining any physical assessment test or not passing the mile test will be consider a lack of physical readiness.

Your payment amount will be refunded, and you will not be admitted to the PCU program.

Later when you are physically ready you may reapply; however, you may only reapply once. The same physical assessments are required on your second consideration to the program.

ACTIVITY READINESS QUESTIONNAIRE

Regular exercise is associated with many health benefits, yet any change of activity may increase the risk of injury. Completion of this questionnaire is a first step when planning to increase the amount of physical activity in your life. Please read each question carefully and answer every question honestly.

If you answered YES to any of the above questions, talk to your doctor BEFORE you become more physically active. Tell your doctor your intent to exercise and to which questions you answered YES.

If you honestly answered NO to all questions above, you can be reasonably positive that you can safely increase your level of physical activity gradually. Be advised if you answer NO on any question and it is later determined that you falsified your answer you will be dismissed from the program.

If your health changes so you then answer YES to any of the above questions, seek guidance from a physician.

HEALTH HISTORY QUESTIONNAIRE

1. Are you aware or has a doctor/health professional ever revealed that you or members of your family (grandparents, parents, or siblings) have ever had any of the following conditions in yours or their medical history?

It is agreed and understood that participating in physical exercise and conditioning is inherently dangerous and that certain physiological changes may occur that may result in dizziness, fainting, stroke, stroke, blindness due to stroke, heart failure, permanent disability, and / or death.

If you have knowingly or unknowingly falsified any part of the Activity Readiness or Health History Questionnaire which hides a health condition and / or ailment, you may be expelled from Pit Instruction & Training’s (PIT) Pit Crew U and 5 Off 5 On Race Team Performance programs due to assumed and perceived liability risks caused by doing so that may lead but are not limited to injury and / or death.

I, for myself, my heirs, executors and legal representatives, hereby waive, release, indemnify and agree to hold harmless Pit Instruction and Training, LLC, its parent, subsidiary and affiliated companies, their officers, directors, agents, and contractors and employees, the owners, leasers and lessees of the facility and equipment used in connection with this activity and other participants from and against any and all claims (including but not limited to personal injury, death, or property damage), damages fees, expenses or costs of any kind, including attorney fees, incurred in connection with such physical exercise and known or unknown health conditions and / or ailments which may at any time be brought, claimed, or asserted.