AFRICA-OFFROAD RACING ENTRY FORM - BIKES & QUADS Step 1 of 6 - EVENT 16% Please select an event and championship typeEVENT*--- PLEASE SELECT AN EVENT ---Doornbult (28 August 2021)Ottosdal (25 September 2021)Coligny Bodenstein 200 (23 October 2021)Hartbeesfontein (4 December 2021)CHAMPIONSHIP TYPE*--- PLEASE SELECT CHAMPIONSHIP TYPE ---ClubRegionalClub + RegionalNational 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 FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin 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 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 EmailThis field is for validation purposes and should be left unchanged.
