Entry Form

MIDVAAL 26 MAY 2012 Permit No. 12133

Competition Number
Entrant Name
Entrant  Licence Number
Rider Name
Licence Number
Nationality
Address
Telephone Number
Fax Number
E-mail Address
Club
ID Number
Emergency Contact
Motorcycle Make
Motorcycle Model
Capacity
Class Must Select
   

 i) I understand that should I at the time of an event in which I intend taking part, be suffering from any condition/disability (whether permanent or temporary) which is likely to prejudicially affect my control of my vehicle/machine, I may not take part in the event concerned unless expressly permitted to do so by MSA following declaration/disability. I further understand that, notwithstanding the issue of a licence to me by MSA it remains my responsibility not to participate in any event where a condition or disability suffered by me, may in anyway affect my or other person’s safety. ii)  I declare that, to the best of my belief, or the driver(s)/ rider(s) entered by me possess the the standard of competence necessary to take part in any event entered, and that anyvehicle/machine entered will be suitable and raceworthy, having regard to the high speeds which will be reached. iii) I declare that any vehicle/machine entered by me, will comply with all regulations andspecifications pertaining to the event entered/catergory of motorsport concerned. I accept,subject to my rights of protest and appeal, that action will be taken against me, as theentrant driver or rider, in accordance with the provisions of MSA.s regulations, if my vehicle/machine is found not to comply with the relevant regulations and specifications.

Must select I Agree
   
I hereby agree to be attended by doctors/paramedics if I am injured and wish to be transported to the
type of hospital indicated.
PLEASE NOTE THAT IF YOU HAVE INDICATED THAT YOU WISH TO BE
TREATED AT A PRIVATE FACILITY IT IS ESSENTIAL THAT YOU COMPLETE THE FOLLOWING
SECTION AND PROVIDE PROOF OF MEDICAL AID/MEDICAL INSURANCE TO GUARANTEE YOUR
ADMISSION TO A PRIVATE FACILITY FAILING WHICH YOU WILL BE TRANSPORTED TO THE NEAREST MEDICAL FACILITY

 
MED AGREE
MEDICAL INFORMATION  
Personal Doctor
Doctor Phone Number
Current Medication
Allergies
Blood Group
Have you sustained a recent injury if so specify
Medical Aid
Medical Aid Number
Principal member

BANK DETAILS:  

Acc Name MS 2000
Standard Bank - Menlyn Branch
Branch Code 012345
Acc No 411298216

 FAX NUMBER 086-5120-295

 

                     

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