Bikes & Quads Online Entries "*" indicates required fields Step 1 of 7 - EVENT 14% Please select an event and championship typeEVENT*--- PLEASE SELECT AN EVENT ---Hartbeesfontein 150 (2 December 2023)CHAMPIONSHIP TYPE*--- PLEASE SELECT CHAMPIONSHIP TYPE ---ClubRegionalClub + RegionalNationalWarrior Class (3 Laps)Warrior Class (4 Laps) Rider License DetailsNAME* SURNAME* DATE OF BIRTH* ID NUMBER WOMZA LICENSE NUMBER LICENSE STATUS CLUB NAME ADDRESS Street Address Address Line 2 Town / City Province Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country TELEPHONE* TELEPHONE (WORK) FAX NO. EMAIL* MEDICAL AID/INSURANCE DETAILS FOR HOSPITAL ADMISSION PURPOSESI 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?--- PLEASE SELECT ---YESNOIF YES, HAVE YOU BEEN CLEARED AS MEDICALLY FIT?--- PLEASE SELECT ---YESNOEMERGENCY PERSONS NAME & CONTACT NUMBER RELATIONSHIP BIKE OR QUAD DETAILSMAKE YEAR MODEL ENGINE MAKE ENGINE CAPACITY NO. OF CYLINDERS REGISTRATION NUMBER CLASS DETAILSPLEASE CHOOSE WHICH CLASS YOU ARE ENTERINGMOTORCYCLES--- PLEASE SELECT CLASS ---OR3 200ccOR2 250ccOR1 OpenSENIORSLADIESMASTERSKIDDIES & JUNIOR BIKES--- PLEASE SELECT CLASS ---BIKES KIDDIES 6 –10 YearsBIKES JUNIOR 10-14 YearsBIKES JUNIORSENIOR 14-17QUADS--- PLEASE SELECT CLASS ---Q1 16-27yearsQ2 28-34yearsSENIORLADIESMASTERSKIDDIES & JUNIOR QUADS--- PLEASE SELECT CLASS ---QUADS KIDDIES 6-10 YearsQUADS JUNIOR 10-14 YearsQUADS JUNIOR/SENIOR14-17 YearsCompetition NumberRACE NUMBER VEHICLE SCRUTINEERINGCOMPETITION NUMBER VISIBLE? QUADS - FRONT & BACK. BIKES - FRONT & BOTH SIDES*YesNoRACE WEAR: LONG SLEEVE, SHIRT & PANTS*YesNoSELF CLOSING THROTTLE?*YesNoBALL END CLITCH & BRAKE LEVER?*YesNoFUEL LINES?*YesNoKIDNEY BELT?*YesNoELBOW GUARDS?*YesNoGLOVES?*YesNoCHEST PROTECTION?*YesNoHELMET & GOGGLES?*YesNoKNEE GUARDS?*YesNoFRONT BRAKES?*YesNoDEAD MAN SWITCH?*YesNoNERVE BARS?*YesNoFULL RACE BOOTS?*YesNoFOLDING FOOT PEGS?*YesNoMUD GUARDS?*YesNoWATER? (min 2lt)*YesNoMEDICAL KIT?*YesNoMEDICAL BOARD CROSS, OK BOARD?*YesNo 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 PhoneThis field is for validation purposes and should be left unchanged.
