P.O Box 1927 Kununurra W.A 6743
President: Louise Schubert Ph: 0417 296 540
Vice President: Dippa Goldup Ph: 0447 014 090
Secretary: Jemma Ninness Ph: 0419 995 591
Treasurer: Charmaine Dawe Ph: 0447 784 864
Email: [email protected]
2017 Membership Application Form
Family Name
Postal Address
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All new License applicant MUST immediately on receipt of their license, inform the Club Secretary of
your License
Number, expiry date and allocated racing number.
All Club License Holders will be given numbers and MUST have their number displayed on their bike at
all times.
All riders/practice supervisor need First Aid accreditation certificate
All Members are required to provide a least 1 Flag person Per race round
All Members are required to participate in at least 1 busy bee per year
2017 MEMBERSHIP FEES (including GST)
FAMILY - $100.00 + $25 per rider (Practice Track Fees)
SINGLE - $80.00 (+18 yrs) Inc Practice Track Fees
SOCIAL- $25 (+18 yrs) NON-RIDER
Key Deposit - $50.00
Amount Payable: ____________
Bank Account Details – Kununurra Motocross Club BSB: 066-530 Account Number: 10189378
Reference – Name
Member 1 (Adult)
Family Name
Email (write clearly)
Contact Phone #
Date of Birth
First Name
SIGN
Mobile #
Current MA License #
Racing #
Member 2 Family Members – Partner/Dependants (up to 18yrs) living together
Family Name
Email (write clearly)
Contact Phone #
Date of Birth
First Name
SIGN
Mobile #
Current MA License #
Racing #
First Name
Current MA License #
Racing #
First Name
Current MA License #
Racing #
First Name
Current MA License #
Racing #
First Name
Current MA License #
Racing #
Member 3
Family Name
Date of Birth
Member 4
Family Name
Date of Birth
Member 5
Family Name
Date of Birth
Member 6
Family Name
Date of Birth
When joining as a family member can you please put all immediate family on
form (riders and non-riders)
Warning! This membership form and the general rules forms are important legal documents which
affect your legal rights and obligations. Read all forms carefully, and do not sign them unless you are
satisfied and understand them totally, and agree to be bound by them.
(1) That I/WE (print rider
name/s)...............................................................................................................................
(Print parent/guardian
names/s).............................................................................................................................
Hereby agree with the persons, organisations and bodies corporate whose names appear in
schedule 1 (hereinafter collectively called the organisers) that I am by this agreement entitled to
participate in the motorcycle activity/meeting held at the Kununurra Motocross Club Inc. on the
terms and conditions set out in this document.
ACKNOWLEDGEMENT OF RISKS, DANGERS AND OBLIGATIONS.
I acknowledge that motorcycle sport is dangerous and that by engaging in the sport and
participating I take am exposed to certain risks and dangers and am under certain obligations as
follows.
(a) That I may be injured physically or mentally and may be killed
(b) That my machinery or equipment may be lost, damaged or destroyed
(c) That other riders may ride dangerously or with lack of skill
(d) That track or event conditions may be hazardous and may vary without warning or
predictability.
(e) That organisers, officials, landowners/track operators and any agents or representatives of
those in charge of the club are frequently obligated to make decisions under pressure of time/ or
events
(f) That any policy of insurance of or in respect of my life or physical or mental health may be
voided.
(g) That there may be no or inadequate facilities for treatment or transport of me if I am injured.
(h) That I have an obligation to myself and others to compete safely and within the rules of
competition and club.
INDEMNITY GIVEN TO ORGANISERS.
In the consideration of the acceptance of me as a member to the Kununurra Motorcycle Club, I
agree to indemnify the organisers and members in the following manner.
(a) That I participate at my sole risk and responsibility.
(b) That I accept the venue as it stands with all or any defects hidden or exposed.
(c) That I indemnify and hold harmless the organisers, their respective servants, agents or officials
against my actions or claims which may be made by me or on behalf for or in respect of or arising
out of my death or any injury loss or damage caused to me or my machinery or equipment
whether caused by negligence, breach of contract or in any other matter whatsoever.
SCHEDULE 1
KUNUNURRA MOTORCYCLE CLUB
Lot 682 Ivanhoe road Kununurra WA 6743
DRUG AND ALCOHOL POLICY
Kununurra Motocross Club condemns the use of performance enhancing and judgement impairing
drugs and doping practices in sport. The use of these drugs and doping practices is contrary to
the ethics of sport and potentially harmful to health. Kununurra Motocross Club will fully support
the Motorcycling Australia’s Anti-Doping Policy as stated in the GCR’s and any subsequent changes
that may take place. A copy of Motorcycling Australia’s General Competition rules will be issued
with all National Licences and will be available to be studies at the Kununurra Motocross club
monthly meetings.
MEMBER OR PARENT/LEGAL GUARDIAN NAME AND SIGNATURE
NAME: ______________________________________________
SIGNATURE: _________________________________________
ADDRESS (if different to address on membership form):
____________________________________________________________
____________________________________________________________
CONTACT PHONE NUMBERS:
Day time____________________________________
After Hours: _________________________________
Mobile: _____________________________________
EMAIL._______________________________________
DATE: ___________________________
KEY HOLDER RULES
PLEASE READ THIS CAREFULLY AND SIGN BELOW
*It is YOUR responsibility to close gate behind you IMMEDIATELY after entry and exit to
the track
*DO NOT let Non-Kununurra Motocross Members into the track
*You must have a non-riding level 1 official in attendance with you while you are practising
and you must have a valid MWA licence to practice (Level 1 officials will be listed on the
KNX website)
*Your key is not to be lent out to anyone
*65cc (beginners) and below ONLY on Front Track
* Juniors and Seniors MUST NOT ride on track together; neither must 2 and 4 wheel bikes
*Riders and officials must sign in on arrival to track in riders + official’s sign on book
located at the starting shed
-When you don’t sign in, not only are you putting yourself at risk and waiving any insurance
cover for you and the club, you are also breaking our rules and MWA rules and jeopardising
the right to practice for the whole club, if a MWA official catches someone practising that
has not signed on, then they will immediately terminate the clubs right to practice and no one
will be allowed to practice anymore.
This is your FIRST and FINAL WARNING. Members caught breaking these rules will have
their keys confiscated immediately and you must attend the next club meeting where you
will have to explain to the committee members why you should still be a member of the
Kununurra Motocross Club
I, the undersigned, state that I have read and understood the rules above and I agree to these
rules as stated.
Print Name:_________________________________________________________
Signature:______________________________________