Delaware Park Horse Racing and Slots

Please print and complete this form in its entirety. Guests may enter only the last four digits of their social security number if so desired. Please mail or fax(302-993-2365) the form as per the directions below.

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and mail to:
Player Rewards Club
777 Delaware Park Blvd.
Wilmington, DE 19804

Player's Club Member Information

Name

_______________________________________________________________________________

Address

_______________________________________________________________________________

City

_______________________________________

State

__________

Zip

____________________

Phone

( ) ______________________________

SSN

______________________________________

Players Club Account #

_____________________________________

Please release information concerning my slot/track activity for the period ending _____/_____/_____

I request that Delaware Park provide my gaming activity for the time period as indicated. I understand that Delaware Park makes no representation of warranty, express or implied, as to the accuracy of this information or its effectiveness as proof of losses nor is it intended to take the place of my own records of gaming activity. In consideration of providing this information, I release Delaware Park and affiliated companies from any and all claims arising from or relating to the information and its release, and further agree to indemnify and hold those entities and persons harmless from any such claim.

Signature

______________________________________

Date

_______________________

EMPLOYEE USE ONLY

Player's Account	________________________________	Last Name	___________________________

ID Number	________________________________	State Issued	___________________________

Verified By	________________________________	Badge	___________________________

Date Picked Up	_________/____________/__________	Date Mailed	________/__________/________

Date Win/Loss Printed	________________________________	Date Filed	________/__________/________


	Copyright © 2013 Delaware Racing Association Contact Information

The Delaware Council on Gambling Problems offers confidential assistance to gamblers, their families, and to those who are concerned about a friend or colleague. The Council provides literature, support meeting information, treatment information, and 24-hour help. Speakers are available for community groups and for professional training.
HELPLINE 888-850-8888 | www.dcgp.org