Entry Form - Off Road Racing - Australia
Entry Form - Off Road Racing - Australia
Entry Form - Off Road Racing - Australia
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BRISBANE SPORTING CAR CLUB LTD<br />
PO Box 3529 South Brisbane B C. Q 4101<br />
2006 - ENTRY FORM<br />
OFFROAD EVENT<br />
Car No<br />
EVENT BEAUREPAIRES Goondiwindi 400 14/15 October 06 CLUB BRISBANE SPORTING CAR CLUB LTD<br />
ENTRANT (CAR OWNER)<br />
NAME ..........................................................................................<br />
ADDRESS ...................................................................................<br />
.............................................................Post Code ......................<br />
ATTRIBUTED ENTRANT/SPONSOR (OPTIONAL)<br />
NAME<br />
..........................................................................................<br />
ADDRESS ................................................................................<br />
.............................................................Post Code ...................<br />
PHONE LICENCE No. PHONE LICENCE No.<br />
B.H. .........................................<br />
A.H. ........................................<br />
CAMS<br />
.....................……………..<br />
B.H. .......................................<br />
A.H. .......................................<br />
CAMS<br />
.....................……………..<br />
DRIVER<br />
NAVIGATOR 1<br />
NAME .........................................................................................<br />
ADDRESS ...................................................................................<br />
............................................................Post Code .......................<br />
NAME .......................................................................................<br />
ADDRESS ................................................................................<br />
............................................................Post Code .....................<br />
PHONE LICENCE Nos. PHONE LICENCE Nos.<br />
B.H. (....)..................................<br />
CAMS ……….......................<br />
B.H. (.....)...............................<br />
CAMS ……….......................<br />
A.H..(....)..................................<br />
GRADE……………………….<br />
A.H..(.....)................................<br />
GRADE……………………….<br />
Club.........................................<br />
CIVIL ....................................<br />
Club.........................................<br />
CIVIL ...................................<br />
M/Ship No...............................<br />
M/Ship No...............................<br />
CO/DRIVER<br />
NAME .........................................................................................<br />
ADDRESS ...................................................................................<br />
............................................................Post Code ......................<br />
NAVIGATOR 2<br />
NAME .......................................................................................<br />
ADDRESS ................................................................................<br />
............................................................Post Code .....................<br />
PHONE LICENCE Nos. PHONE LICENCE Nos.<br />
B.H..(....)..................................<br />
CAMS ……. ..........................<br />
B.H..(.....)................................<br />
CAMS ……….......................<br />
A.H..(....)..................................<br />
GRADE……………………….<br />
A.H. (.....)................................<br />
GRADE………………………<br />
Club.........................................<br />
CIVIL ....................................<br />
Club.........................................<br />
CIVIL ...................................<br />
M/Ship No................................<br />
M/Ship No...............................<br />
DESCRIPTION OF CAR<br />
MAKE MODEL CAPACITY<br />
COLOUR BODY TYPE CLASS<br />
PAYMENT<br />
I/We enclose<br />
$ ______________Early <strong>Entry</strong> Fee by 18 September $480.00 or <strong>Entry</strong> Fee between 18 September and close of entries<br />
$510.00<br />
$ ______________ Extra crew member/s at $20.00 Please indicate Payment Method<br />
$ ______________ Extra Pit Passes at $10 each Cheque Money Order Cash<br />
$ ______________ TOTAL (GST included) or by Credit Card Visa Mastercard Bankcard<br />
Card No<br />
Card Name: ............................................................................. Signature: ........................................................................<br />
Expiry Date: ....................................................<br />
Please tick the box if you require a Tax Invoice BSCC ABN No: 18010180266<br />
Post entries to:- Event Secretary BEAUREPAIRES Goondiwindi 400<br />
PO Box 3529 ,South Brisbane BC Qld 4101<br />
Note:- Early Entries (for discount) close at 5.00pm Friday 29 September 2006<br />
Entries close at 5.00pm Friday 6th October 2006<br />
2006 AORC <strong>Entry</strong> <strong>Form</strong> Goondi Final.doc<br />
Please complete over
ENTRANTS and COMPETING CREW MEMBERS’ DISCLAIMER STATEMENT<br />
I/We being the entrant/s and/or driver and/or co-driver and/or navigator, certify that the particulars on this form are true and correct in every<br />
particular, to the best of my/our knowledge and belief. I/We declare that I/we have read and understood the Supplementary Regulations<br />
issued for the event, and agree to be bound by them and the provisions of the National Competition Rules of the Confederation of<br />
<strong>Australia</strong>n Motor Sport Limited (“CAMS”). In exchange for being able to attend or participate in the event (including entering the event),<br />
- I agree:to release CAMS and <strong>Australia</strong>n Motor Sport Commission Ltd, promoters, sponsor organisations, land owners and lessees,<br />
organisers of the event, their respective servants, officials, representatives and agents (collectively, the "Associated Entities") from all<br />
liability for my death, personal injury (including burns), psychological trauma, loss or damage (including property damage) ("harm")<br />
howsoever arising from my participation in or attendance at the event, except to the extent prohibited by law;<br />
- that CAMS and the Associated Entities do not make any warranty, implied or express, that the event services will be provided with due<br />
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<br />
- to attend or participate in the event at my own risk.<br />
I/we acknowledge that:<br />
- the risks associated with attending or participating in the event include the risk that I may suffer harm as a result of:<br />
motor vehicles (or parts of them) colliding with other motor vehicles, persons or property;<br />
- acts of violence and other harmful acts (whether intentional or inadvertent) committed by persons attending or participating in the event;<br />
and<br />
- the failure or unsuitability of facilities (including grand-stands, fences and guard rails) to ensure the safety of persons or property at the<br />
event.<br />
- motor sport is dangerous and that accidents causing harm can and do happen and may happen to me.<br />
I accept the conditions of, and acknowledge the risks arising from, attending or participating in the event and being provided with the event<br />
services by CAMS and the Associated Entities.<br />
I understand that this disclaimer is not intended to exclude any valid claim I may have under the CAMS Personal Insurance Scheme.<br />
Entrant’s Signature: .......................................Date..../..../......<br />
Driver 1 Signature:.........................................Date....../...../......<br />
Nav 1 Signature:.........................................Date....../...../......<br />
Co/Driver<br />
Signature:.........................................Date....../...../......<br />
Nav 2 Signature:.........................................Date....../...../......<br />
PARENT/LEGAL GUARDIAN CONSENT<br />
I am the parent/ guardian* of the above-named ("the minor") who is under 18 years old. I have read this document and understand its am<br />
the contents, including the exclusion of liability and assumption of risk, and have explained the contents to the minor. I consent to the<br />
minor attending/ participating in the event at his/her own risk.<br />
PARENT/GUARDIAN* (Delete which does not apply)<br />
NAME ........................................................................................<br />
ADDRESS .................................................................................<br />
............................................................Post Code ......................<br />
Signature …………………………………………………………….<br />
Crew Member……………………………………………………….<br />
PARENT/GUARDIAN* (Delete which does not apply)<br />
NAME .......................................................................................<br />
ADDRESS ................................................................................<br />
............................................................Post Code .....................<br />
Signature …………………………………………………………….<br />
Crew Member……………………………………………………….<br />
PARENT/GUARDIAN* (Delete which does not apply)<br />
PARENT/GUARDIAN* (Delete which does not apply)<br />
NAME ........................................................................................ NAME .......................................................................................<br />
ADDRESS ................................................................................. ADDRESS ................................................................................<br />
............................................................Post Code ...................... ............................................................Post Code .....................<br />
Signature ……………………………………………………………. Signature …………………………………………………………….<br />
Crew Member………………………………………………………. Crew Member……………………………………………………….<br />
PRIVACY STATEMENT<br />
BSCC requires the information on this <strong>Entry</strong> <strong>Form</strong> to accept your entry for this event. Your personal information will only be used in<br />
relation to this event. However, as the Entrant I consent to my contact details being made available to other clubs to be used to<br />
mail out regulations and event information.<br />
Please tick the box if you do not wish this to happen.<br />
I will attend scrutiny at................................................................on................................................................<br />
Note:- Please complete PIT CREW SIGN ON SHEET and PROMOTION SHEET and<br />
return with entry<br />
2006 AORC <strong>Entry</strong> <strong>Form</strong> Goondi Final.doc
PIT CREW SIGN ON SHEET<br />
CAR NUMBER<br />
Driver<br />
PIT CREW DISCLAIMER STATEMENT<br />
(To be completed by all Pit Crew members)<br />
In exchange for being able to attend or participate in the event, I agree:<br />
- to release Confederation of <strong>Australia</strong>n Motor Sport Ltd ("CAMS") and <strong>Australia</strong>n Motor Sport Commission Ltd, promoters, sponsor<br />
organisations, land owners and lessees, organisers of the event, their respective servants, officials, representatives and agents<br />
(collectively, the "Associated Entities") from all liability for my death, personal injury (including burns), psychological trauma, loss or<br />
damage (including property damage) ("harm") howsoever arising from my participation in or attendance at the event, except to the<br />
extent prohibited by law;<br />
- that CAMS and the Associated Entities do not make any warranty, implied or express, that the event services will be provided with due<br />
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<br />
- to attend or participate in the event at my own risk.<br />
I acknowledge that:<br />
- the risks associated with attending or participating in the event include the risk that I may suffer harm as a result of:<br />
- motor vehicles (or parts of them) colliding with other motor vehicles, persons or property;<br />
- acts of violence and other harmful acts (whether intentional or inadvertent) committed by persons attending or participating in the event;<br />
and<br />
- the failure or unsuitability of facilities (including grand-stands, fences and guard rails) to ensure the safety of persons or property at the<br />
event.<br />
- motor sport is dangerous and that accidents causing harm can and do happen and may happen to me.<br />
I accept the conditions of, and acknowledge the risks arising from, attending or participating in the event and being provided with the<br />
event services by CAMS and the Associated Entities.<br />
I understand that this disclaimer is not intended to exclude any valid claim I may have under the CAMS Personal Insurance Scheme.<br />
PIT CREW MEMBER 1<br />
NAME .......................................................................................<br />
(Please Print)<br />
SIGNATURE.................................................................................<br />
PIT CREW MEMBER 3<br />
NAME .......................................................................................<br />
(Please Print)<br />
SIGNATURE.................................................................................<br />
PIT CREW MEMBER 5<br />
NAME .......................................................................................<br />
(Please Print)<br />
SIGNATURE.................................................................................<br />
PIT CREW MEMBER 7<br />
NAME .......................................................................................<br />
(Please Print)<br />
SIGNATURE.................................................................................<br />
PIT CREW MEMBER 2<br />
NAME ....................................................................................<br />
(Please Print)<br />
SIGNATURE...........................................................................<br />
PIT CREW MEMBER 4<br />
NAME ....................................................................................<br />
(Please Print)<br />
SIGNATURE...........................................................................<br />
PIT CREW MEMBER 6<br />
NAME ....................................................................................<br />
(Please Print)<br />
SIGNATURE...........................................................................<br />
PIT CREW MEMBER 8<br />
NAME ....................................................................................<br />
(Please Print)<br />
SIGNATURE...........................................................................<br />
PARENT/LEGAL GUARDIAN CONSENT<br />
I am the parent/ guardian* of the above-named ("the minor") who is under 18 years old. I have read this document and understand the<br />
contents, including the exclusion of liability and assumption of risk, and have explained the contents to the minor. I consent to the minor<br />
attending/ participating in the event at his/her own risk.<br />
PARENT/GUARDIAN* (Delete which does not apply)<br />
NAME ......................................................................................<br />
ADDRESS ...............................................................................<br />
............................................................Post Code ...................<br />
Signature …………………………………………………………..<br />
Crew Member………………………………………………………<br />
PARENT/GUARDIAN* (Delete which does not apply)<br />
NAME ......................................................................................<br />
ADDRESS ...............................................................................<br />
...........................................................Post Code.....................<br />
Signature …………………………………………………………..<br />
Crew Member………………………………………………………<br />
PARENT/GUARDIAN* (Delete which does not apply)<br />
NAME .......................................................................................<br />
ADDRESS ................................................................................<br />
............................................................Post Code .....................<br />
Signature …………………………………………………………….<br />
Crew Member……………………………………………………….<br />
PARENT/GUARDIAN* (Delete which does not apply)<br />
NAME .......................................................................................<br />
ADDRESS ................................................................................<br />
............................................................Post Code .....................<br />
Signature …………………………………………………………….<br />
Crew Member……………………………………………………….<br />
PLEASE RETURN THIS FORM WITH YOUR ENTRY FORM<br />
2006 AORC <strong>Entry</strong> <strong>Form</strong> Goondi Final.doc
PROMOTIONAL INFORMATION<br />
CAR NUMBER<br />
Driver<br />
Age<br />
Occupation<br />
Navigator<br />
Age<br />
Sponsored by<br />
…………………………………………………………………………………<br />
…………………<br />
…………………………………………………………………………………<br />
…………………………………………………………………………………<br />
…………………<br />
…………………………………………………………………………………<br />
…………………………………………………………………………………<br />
Make of Car<br />
Engine Type<br />
Engine Capacity<br />
Previous<br />
Performances<br />
…………………………………………………………………………………<br />
………………………………….<br />
…………………<br />
…………………………………………………………………………………<br />
…………………………………………………………………………………<br />
…………………………………………………………………………………<br />
…………………………………………………………………………………<br />
…………………………………………………………………………………<br />
PLEASE RETURN THIS FORM WITH YOUR ENTRY FORM<br />
2006 AORC <strong>Entry</strong> <strong>Form</strong> Goondi Final.doc
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