Bikes & Quad Online Entry – Africa Offroad Racing

AFRICA-OFFROAD RACING ENTRY FORM - BIKES & QUADS

Step 1 of 6 - EVENT

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

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