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RIDER SELF DISCHARGE FORM<br />

ROAD RACING SUPERBIKE & SUPERSPORT<br />

WORLD CHAMPIONSHIPS AND SUPERSTOCK CUP<br />

PART 1: To be completed by the rider<br />

I, rider no<br />

in the class, discharge myself against local medical advise<br />

and understand the possible consequences.<br />

Signed: Date : Time :<br />

PART 2: To be completed by the Chief Medical Officer (CMO)<br />

I, Dr , CMO at the<br />

circuit, confirm that I have<br />

explained the possible consequences of the rider discharging himself/herself.<br />

In view of the language difficulties, this explanation was given through an<br />

interpreter (Delete if inappropriate).<br />

Signed: Date : Time :<br />

5 Copies: CMO, Rider, Clerk of the Course, Medical Director, Clinica Mobile<br />

180

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