DATE OF MEETING:                    /                      /    2011

Class:

Race No:

First Name:

Surname:

Transponder Number:

Txp

Chassis:

Novice:

Yes  o No  o

Engine:

Licence No:

Club:

Licence Type:

A  o   C  o   B  o   B(Novice) q

Entrant:

Entrants Licence No:

Your Address:

Town:

Post Code:

Tel No:

Email:

enables automatic confirmation

Name of person to contact in case of Emergency:

Post Code:

Tel No:

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.  Further, I understand that all person having any connection with the promotion and/or organization and/or conduct of the event are insured against loss or injury caused through their negligence.

I declare that to the best of my belief the drier possesses 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 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 declared such disability to the ASN which has, following such declaration, issued a licence which permits me to do so.

I undertake that at the time of the event to which this entry relates I shall have passed or am exempt from an ASN specified medical examination within the specified period [C(a)-26]

As the Parent/Guardian/Guarantor of the driver:

I understand that I shall have the right to be present during any procedure being carried out under the Supplementary Regulations issued for this event and the General Regulations of the MSA.

I confirm that I have acquainted myself with the MSA General Regulations, agree to pay any appropriate charges and fees pursuant to those Regulations (to include any appendices thereto) and hereby agree to be bound by those Regulations and submit myself without reserve to the consequences resulting from those Regulations (and any subsequent alteration thereof). Further, I agree to pay as liquidated damages any fines imposed upon me up to the maxima set out in Part 3 Appendix 3

NOTE:  Where the Parent/Guardian/Guarantor is not present there must be a representative who must produce a written and signed authorisation to so act from the Parent/Guardian/Guarantor as appropriate.

Signed:

Name:

Address:

Signed:

Date:

Age if under 18 yrs:

£

.

Card No:

Start Date:

Expiry Date:

Security Code:

Issue No:

Name on Card:

Signature: