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Autotest September 2017 Entry Form
mediaistic
2017-09-05T12:55:35+01:00
Step 1 of 4
25%
About the Driver
We need to collect some information about the driver. Please ensure you fill this form out with as much accuracy as possible.
Drivers Name
*
First
Last
Is the Driver 18 or over?
*
Yes the driver is 18 or over.
No, the driver is under 18
What is the drivers age?
*
Drivers Address
*
Street Address
Address Line 2
City
County
Post Code
Drivers Email
*
Drivers Phone Number
*
Drivers Mobile Number
if different to above
Does the driver hold a Driving Licence?
*
Yes
No
About Your Club
Please let us know which club you are a member of, and your membership number.
Drivers Club
*
Drivers Membership Number
*
MSA Competition Licence Number
Drivers Emergency Contact
Please let us know who to contact in the event of an accident or emergency.
Drivers Emergency Contact
*
First
Last
Emergency Contacts Number
*
About the Passenger / Navigator
We need some details about your passenger / navigator.
Will you be carrying a passenger / navigator?
*
Yes
No
Passengers Name
*
First
Last
Is the Passenger 18 or over?
*
Yes the passenger is 18 or over.
No, the passenger is under 18
What is the passengers age?
*
Passengers Address
*
Street Address
Address Line 2
City
County
Post Code
Passengers Email
*
Passengers Phone Number
*
Passengers Mobile Number
if different to above
About Your Passengers Club
Please let us know which club your passenger is a member of, and their membership number.
Passengers Club
*
Passengers Membership Number
*
Passengers Emergency Contact
Please let us know who to contact in the event of an accident or emergency.
Passengers Emergency Contact
*
First
Last
Passengers Emergency Contacts Number
*
About Your Entry
Make of Car
*
Model of Car
*
Engine CC
*
Registration Number
*
Colour
Class Entered
*
Indemnification & Declaration
You will be required to sign a copy of this at the event. If you or your passenger are under the age of 18 - a parent or legal guardian must also sign the form.
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 motor sport 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 anyone 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 not limited to damage to property, economic loss, consequential loss or financial loss howsoever caused. Nothing in this clause is in 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.
Acceptance
*
I have read, understand and accept the above indemnification and declaration.
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