MBKC 3S Race Entry Form 2010
To print this form click on the printer icon, top right, then click the printer icon in the windows that pops up with a correctly formatted form
Race Meeting at Three Sisters Race Circuit, Wigan. on:…………………………
|
DRIVER'S NAME
|
||||
|
ADDRESS
|
||||
|
TELEPHONE
NUMBER |
HOME
|
Mobile
|
||
|
MEMBER OF WHICH CLUB
|
e-mail address: | |||
|
LICENCE NUMBER
|
LICENCE
TYPE |
NAT A / NAT B / INT
|
||
|
NOVICE
|
YES / NO | |||
|
KART NUMBER
|
(an alternate number maybe allocated) | |||
|
KART CHASSIS
|
KART ENGINE
|
|||
|
CLASS ENTERING
|
||||
|
PRE-BOOK PRACTICE
or Pay on the Day |
Members: Friday £30 / Saturday £30 Non Members : Friday £40 / Saturday £40 Delete as appropriate |
|||
|
OWN
TRANSPONDER |
YES / NO (if no, please enclose £5 for hire) |
TRANSPONDER NUMBER | ||
I have read the Supplementary regulations issued for this event and agree to be bound by them and by the general Regulations of the MSA Ltd, in consideration of the acceptance of this entry or of my being permitted to take part in the event. I agree to save harmless and keep indemnified the MSA Ltd such person. Persons or body as may be authorised by the MSA Ltd to promote or organise this event and their perspective officials, servants, representatives and agents from and against all actions, claims, costs expenses and demands in respect of death or injury to myself howsoever caused arising out of or in connection with this entry or my taking part in this event, and not withstanding that the same may have been contributed to or occasioned by the negligence of the said bodies, their officials, servants, representatives or agents. Furthermore, in respect of any parts of this event on ground where third party insurance is not required by law this agreement shall in addition to the parties named above extend to all and any other competitors and their servants and agents and to all actions, claims, costs, expenses and demands in respect of loss or damage to the person or property of myself, my driver(s), passenger(s) or mechanics.
|
AGE
& Date of Birth |
|
SIGNATURE
|
||
“I declare that to the best of my belief the driver posses the standard of competence necessary for an event of the type to which this entry relates and roadworthy for the event having regard to the course and to the speeds which will be reached” I understand that should I at the time of this event be suffering from any disability whether permanent or temporary which is likely to affect prejudicially my normal control of my vehicle, I may not take part unless I have described such disability to the MSA Ltd, who have following such disability, issued a licence which permits me to do so. I undertake that at the time of the event to which the entry relates I shall be in possession of a current valid MSA approved Medical Certificate. By countersigning as parents/guardians/guarantors of minors they agree that they have no objection to still or moving images being taken of the driver undertaking their sporting activities.
|
NAME OF PARENT/GUARDIAN |
||||
|
ADDRESS
|
||||
|
SIGNATURE
|
||||
| NAME & TELEPHONE NUMBER IN THE EVENT OF AN ACCIDENT | ||||
ENTRY FEE: MBKC members £42 (subject to general meeting approval), non-members £53
Hire of Transponder £5 (free hire for novice MBKC members)
Cheques payable to MBKC. PLEASE SEND S.A.E. FOR ACCEPTANCE OF ENTRY.
CLOSING DATE IS SATURDAY PRIOR TO MEETING. NO REFUND IF WITHDRAWN AFTER CLOSING DATE.
PLEASE FORWARD TO: KATH BOTT. LAUNSWOOD, WIGAN ROAD, SHEVINGTON, WIGAN, LANCS, WN6 8PY. TEL 07739 119797 if not available please leave a message or quick text.