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Step 1 of 7 - EVENT

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Please select an event and championship type

EVENT*

CHAMPIONSHIP TYPE*

Rider License Details

NAME*

SURNAME*

DATE OF BIRTH*

ID NUMBER

WOMZA LICENSE NUMBER

LICENSE STATUS

CLUB NAME

ADDRESS

Street Address Address Line 2 Town / City Province Postal Code Country

TELEPHONE*

TELEPHONE (WORK)

FAX NO.

EMAIL*

MEDICAL AID/INSURANCE DETAILS FOR HOSPITAL ADMISSION PURPOSES

I hereby agree to be attended to by doctor/paramedics if I am injured and wish to be transported to the type of hospital indicated*

PRIVATE HOSPITAL

STATE HOSPITAL

MEDICAL AID SCHEME NAME

TYPE OF SCHEME

MEMBERSHIP NUMBER

PRINCIPAL MEMBER

PERSONAL (HOME) DOCTOR

DOCTOR CONTACT NUMBER

MEDICAL CONDITIONS

BLOOD GROUP / ALLERGIES

HAVE YOU SUSTAINED RECENT INJURY/ILLNESS?

IF YES, HAVE YOU BEEN CLEARED AS MEDICALLY FIT?

EMERGENCY PERSONS NAME & CONTACT NUMBER

RELATIONSHIP

BIKE OR QUAD DETAILS

MAKE

YEAR MODEL

ENGINE MAKE

ENGINE CAPACITY

NO. OF CYLINDERS

REGISTRATION NUMBER

CLASS DETAILS

PLEASE CHOOSE WHICH CLASS YOU ARE ENTERING

MOTORCYCLES

KIDDIES & JUNIOR BIKES

QUADS

KIDDIES & JUNIOR QUADS

Competition Number

RACE NUMBER

VEHICLE SCRUTINEERING

COMPETITION NUMBER VISIBLE? QUADS - FRONT & BACK. BIKES - FRONT & BOTH SIDES*

RACE WEAR: LONG SLEEVE, SHIRT & PANTS*

SELF CLOSING THROTTLE?*

BALL END CLITCH & BRAKE LEVER?*

FUEL LINES?*

KIDNEY BELT?*

ELBOW GUARDS?*

GLOVES?*

CHEST PROTECTION?*

HELMET & GOGGLES?*

KNEE GUARDS?*

FRONT BRAKES?*

DEAD MAN SWITCH?*

NERVE BARS?*

FULL RACE BOOTS?*

FOLDING FOOT PEGS?*

MUD GUARDS?*

WATER? (min 2lt)*

MEDICAL KIT?*

MEDICAL BOARD CROSS, OK BOARD?*

CONSENT

I AM OVER 21 AND ACCEPT THAT ALL INFORMATION IS CORRECT

I AM THE PARENT/GUARDIAN OF THIS UNDER 21 YEAR OLD AND ACCEPT THAT ALL INFORMATION IS CORRECT

PARENT / GUARDIAN NAME

PARENT / GUARDIAN CONTACT NUMBER

Phone

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