Cars Online Entry – Africa Offroad Racing

Driver License Details
DRIVER NAME*
DRIVER SURNAME*
DRIVER DATE OF BIRTH*
DRIVER ID NUMBER
DRIVER WOMZA LICENSE NUMBER
LICENSE STATUS
CLUB NAME
DRIVER ADDRESS
Street Address Address Line 2 Town / City Province Postal Code Country
DRIVER TELEPHONE*
DRIVER TELEPHONE (WORK)
DRIVER FAX NO.
DRIVER EMAIL*

DRIVER - 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

Navigator License Details
NAVIGATOR NAME
NAVIGATOR SURNAME
NAVIGATOR DATE OF BIRTH
NAVIGATOR ID NUMBER
NAVIGATOR WOMZA LICENSE NUMBER
NAVIGATOR LICENSE STATUS
CLUB NAME
NAVIGATOR ADDRESS
Street Address Address Line 2 Town / City Province Postal Code Country
NAVIGATOR TELEPHONE
NAVIGATOR TELEPHONE (WORK)
NAVIGATOR FAX NO.
NAVIGATOR EMAIL

NAVIGATOR - 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

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

AFRICA-OFFROAD RACING ENTRY FORM - CARS