Amman & District Motor Club Ltd. Red Kite Stages.

19th February 2017

Entry Form

Please tick as appropriate:

Please use block capitals.

Driver:
Co Driver:
Vehicle Details:
Insurance:
Fees:

Please make sure your cheque/postal order is payable to Red Kite Stages.

For official use only:
RECD: CHQ: BACS: BANKED:
ACK: ENTRY COMPLETE:

Please return to: Jayne Morgan, 33 Gellideg, Pontardawe, Swansea, SA8 4LX.

E-Mail: entrysec@redkitestages.co.uk

To pay by BACS e-mail the entry sec for sort code, account number and unique entry reference number

MSA Indemnity Declaration

'I declare that I have been given the opportunity to read the General Regulations of the Motor Sports Association and, if any, the Supplementary Regulations for this event and agree to be bound by them. I declare that I am physically and mentally fit to take part in the event and I am competent to do so. I acknowledge that I understand the nature and type of the competition and the potential risk inherent with motor sport and agree to accept that risk.'

'I understand that motorsport can be dangerous and accidents causing death, injury, disability and property damage can and do happen. I understand that these risks may give rise to my suffering personal injury or other loss and I acknowledge and accept these risks. In consideration of the acceptance of this entry I agree that neither any one of or any combination of the MSA and its associated clubs, the organisers, the track owners or other occupiers, the promoters and their respective officers, servants, representatives and agents (the "Parties") shall have any liability for loss or damage which may be sustained or incurred by me as a result of participation in the Event including but not limited to damage to property, economic loss, consequential loss or financial loss howsoever caused. Nothing in this clause is intended to or shall be deemed to exclude or limit liability for death or personal injury. To the fullest extent permitted by law I agree to indemnify and hold harmless each of the Parties in respect of any loss or damage whatsoever and howsoever arising from my participation in this event.'

'I declare that to the best of my belief the driver(s) possess(es) the standard of competence necessary for an event of the type to which this entry relates and that the vehicle entered is suitable and roadworthy for the event having regard to the course and the speeds which will be reached'. 'I declare that the use of the vehicle hereby entered will be covered by insurance as required by the law which is valid for such part of this event as shall take place on roads as defined by the law'

'If I am the Parent or Guardian of the driver 'I understand that I shall have the right to be present during any procedure being carried out under the Supplementary Regulations issued for this event and the General Regulations of the MSA.' As the Parent/Guardian 'I confirm that I have acquainted myself and the minor with the MSA General Regulations, agree to pay any appropriate charges and fees pursuant to those Regulations (to include any appendices thereto) and hereby agree to be bound by those Regulations and submit myself without reserve to the consequences resulting from those Regulations (and any subsequent alteration thereof). Further, I agree to pay as liquidated damages any fines imposed upon me up to the maxima set out in Part 3, Appendix 1.' 'I understand that should I at the time of this event be suffering from any disability whether permanent or temporary which is likely to affect prejudicially my normal control of my vehicle, I may not take part unless I have declared such disability to the ASN which has, following such declaration, issued a licence which permits me to do so.' 'I understand that at the time of the event to which this entry relates I shall have passed or am exempt from an ASN specified medical examination within the specified period.'H10.1.6)

'I have read and fully understood the Procedure for Control of Drugs and Alcohol as contained in the Competitors' and Officials' Yearbook Regulations H39, D35.1, G15.1.4 and have also fully familiarised myself with the information on the web sites referred to (www.ukad.org.uk and www.wada-ama.org) in particular the UK Anti Doping Rules which have been adopted by the MSA. Further, if I am counter-signing as the Parent or Guardian of a minor then in addition to the deemed consent to the testing of that minor (UKAD Code Art 5.6.2) I hereby confirm that I give such consent for the minor concerned to be so tested.' 'I hereby agree to abide by the MSA Child Protection Policy and Guidelines and the National Sporting Code of Conduct.'


Entrant Driver Co-Driver
Signature
Age (if under 18)

Any indemnity and/or declaration signed by a person under the age of 18 must be countersigned by their parent or guardian whose full name and address must be stated below. Note: Where the Parent/Guardian/Guarantor is not present there must be a representative who must produce a written and signed authorisation to so act from the Parent/Guardian/Guarantor as appropriate. This entry is made with my consent:-

Signature
Full Name
Address


Seeding Information:

Please state your best results on stage rallies in the last three years. This information will be used to assist seeding and will be checked against available event results.

Date Event Status Surface Overall Class

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