AFRICA-OFFROAD RACING ENTRY FORM - BIKES & QUADS Step 1 of 6 - EVENT 16% Please select an event and championship typeEVENT*--- PLEASE SELECT AN EVENT ---Hartbeesfontein 150 (5 December 2020)CHAMPIONSHIP TYPE*--- PLEASE SELECT CHAMPIONSHIP TYPE ---ClubRegionalClub + RegionalNational Rider License DetailsNAME*SURNAME*DATE OF BIRTH*ID NUMBERWOMZA LICENSE NUMBERLICENSE STATUSCLUB NAMEADDRESS 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 HOSPITALSTATE HOSPITALMEDICAL AID SCHEME NAMETYPE OF SCHEMEMEMBERSHIP NUMBERPRINCIPAL MEMBERPERSONAL (HOME) DOCTORDOCTOR CONTACT NUMBERMEDICAL CONDITIONSBLOOD GROUP / ALLERGIESHAVE YOU SUSTAINED RECENT INJURY/ILLNESS?--- PLEASE SELECT ---YESNOIF YES, HAVE YOU BEEN CLEARED AS MEDICALLY FIT?--- PLEASE SELECT ---YESNOEMERGENCY PERSONS NAME & CONTACT NUMBERRELATIONSHIP BIKE OR QUAD DETAILSMAKEYEAR MODELENGINE MAKEENGINE CAPACITYNO. OF CYLINDERSREGISTRATION 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 CONSENTI AM OVER 21 AND ACCEPT THAT ALL INFORMATION IS CORRECTI AM THE PARENT/GUARDIAN OF THIS UNDER 21 YEAR OLD AND ACCEPT THAT ALL INFORMATION IS CORRECTPARENT / GUARDIAN NAMEPARENT / GUARDIAN CONTACT NUMBER
