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Particulars of Entry:
Drivers Name: ………………………………………………………………………….
Comp Licence No: ……………………… Grade: ……………………………… Club & Membership No : ……………
Driver Address : ……………………………………………………………………………………………………………….
…………………………………………………………………………………………………………………………………..
……………………………………… Postcode: …………………
E-mail: ………………………………………….......
Tel: (Day) …………………………. (Evening) …………………………… Mobile ………………………………………
Has Driver any disability or taking any prescribed drugs which should be notified to Medical Officer: YES / NO
Entrant/Sponsor/Team Name : …………………………………………………………………………………………….
Entrant Address : ……………………………………………………………………………………………………………
Address to which tickets should be sent : ……………………………………………………………………………….
if different from above
………………………………………………………………………………………………………………………………...
Particulars of Car: Make : …………………………………….Model : ……………………………………
Championship Class: ………….. cc: ……….. Year: ………. Preferred Racing (Car) No: …………
Event (Race) Entered:…………………………………………….. Cheque enclosed £ ……………….
Has driver competed at this circuit before: YES / NO
Drivers licence to be signed for upgrade: YES / NO MST Transponder No. …………………..
PAYMENT BY CASH OR CHEQUE. Cheques made payable to:- CLUB MALLORY
NB: ALL SECTIONS OF THIS FORM MUST BE COMPLETED OR ENTRY WILL BE REFUSED
GENERAL DECLARATION - FOR COMPLETION BY ALL COMPETITORS:
I DECLARE THAT:
1. I have been given the opportunity to read the General Regulations of the Motor Sports Association and, if any, the
Supplementary Regs for this event and agree to be bound by them. I declare that I am physically and mentally fit and
competent to take part in the event. I understand that motorsportis dangerous andaccidents cauing death, injury disability
and property damage can and do happen. I understand that these risksmay give rise to my suffering personal injury or other
loss and I acknowledge and accept these risks. In consideration of the acceptance of the entry I agree that neither any one
of or any combination of the MSA and its associated clubs, the organisers, the track owners or other occupiers, the
promoters and their respective officers, servants,representatives and ( the” Parties” ) shallhave any liability for loss or
damage which may be sustained or incurred by me as a result of participation in the event, Nothing in this clause is intended
to or shall be deemed to exclude or limit liability for death or personal injury. To the fullest extent permitted by law I agree to
indemnify and hold harmlesseach of the Parties in respect of any loss or damage whatsoever and howsoever arising from
my participation in the event.
2. I declare that to he best of my belief the driver(s) possess(es) 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.
3. 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.
4. Any application form for a Licence which was signed by a person under the age of 18 years was countersigned by that
person’s parent/legalguardian/guarantor, whose full names and addresses have been given.
5. If I am 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. As the Parent/Guardian/Guarantor I confirm that I have acquainted myself and the minor 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 1 of the 2014 Competitors Yearbook (Blue Book). 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.
6. I hereby agree to abide by the MSA Child Protection Policy and Guidelines and the National Sporting Dode of Conduct.
Parent/Guardian/ Guarantor Signature
State age here if under 18. AGE:
DRIVERS SIGNATURE:
DATE:
NAME AND ADDRESS OF RELATIVE OR PERSON TO BE NOTIFIED IN THE EVENT OF A SERIOUS ACCIDENT.
NAME:
RELATIONSHIP:
ADDRESS:
TELEPHONE: (Day)
(Evening)