All-Girls Motor Sport Day ENTRY FORM July 18 2010
Scanned email (prefer as PDF) or posted forms only. Details may be used for direct promotion by AEM to entrants.
ENTRANT if the same as Driver, fill in DRIVER section, below Name ___________________________Address _____________________________________________________Postcode _______
DRIVER Name __________________________________________________________
Address ____________________________________________________ Postcode _______
Telephone - h _________________ wk __________________ Mobile ___________________
Email __________________________________________________
Date of birth _________ Occupation _________________________
Competition Licence No._______________________ Issuing Club ___________________
LEAVE THIS LINE EMPTY IF YOU REQUIRE ONE
VEHICLE DETAILS Make & model __________________________________________
Year __________ Engine cc ________ Turbo or S/charged? YES / NO 4WD? YES / NO
License type (circle): Full rego - Concessional - Other _______________ Plate No.____________
BEFORE YOU SIGN Check and tick each of the following:
1. I have read and understood the event Regulations. (tick)
2. I understand my responsibility to pay for damage I cause. (tick)
3. I have read the disclaimer below. (tick)
SIGNATURES
Entrant _____________________ date _______ Driver _______________________ date _______
Parent or legal guardian permission required for any driver under 18 years of age. Request a form.
DISCLAIMER - EXCLUSION OF LIABILITY RELEASE & ASSUMPTION OF RISK
I/We being the entrant/s and/or driver, certify that the particulars on this form are true and correct in every particular, to the best of my knowledge and belief. I/We declare that I/we have read and understood the Supplementary Regulations issued for the event and agree to be bound by them and the provisions of the National Competition Rules of the Australian Auto-Sport Alliance Pty Ltd (AASA) - website: www.aasa.com.au. In exchange for being able to attend or participate in the event (including entering the event), I agree: To release AASA, AEM, promoters, sponsor organisations, land owners and lessees, organisers of the event, their respective servants, officials, representatives and agents (collectively the “associated Entities”) from all liability for my death, personal injury (including burns), psychological trauma, loss or damage (including property damage) (”harm”) howsoever arising from my participation in or attendance at the event, except to the extent prohibited by law; That AASA, AEM and Associated Entities do not make any warranty, implied or express, that the event services will be provided with due care and skill or that any materials provided in connection with the services will be fit for the purpose for which they are supplied; and to attend or participate in the event at my own risk. I/we acknowledge that: The risks associated with attending or participating in the event include the risk that I may suffer harm as a result of: Motor vehicles (or parts of them) colliding with other motor vehicles, persons or property; Acts of violence or other harmful acts (whether intentional or inadvertent) committed by persons attending or participating in the event; and the failure or unsuitability of facilities (including grand-stands, fences and guard rails) to ensure the safety of persons or property at the event. Motor sport is dangerous & that accidents causing harm can & do happen and may happen to me. I accept the conditions of, and acknowledge the risks arising from, attending or participating in the event, and being provided with the event services by AASA, AEM and the Associated Entities.
PAYMENT Payment may be made in either of these two ways: Entries without payment will not be accepted.
BY CHEQUE - Cheques can be made out to AEM, and must be sent with this form. Pay $75.
BY CREDIT CARD - In which case, complete the section below. Note that a $1 credit card fee will be applied, so $76 will be deducted from your card. By signing below, you agree to this fee.
Credit card type (circle) - VISA MASTERCARD
Card number - __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ Expiry - ___/___
Cardholders name - _________________________ Signature - ______________________AUTOMOTIVE EVENTS MANAGEMENT PO Box 1222, Subiaco, 6008 info@classicrally.com.au