Documents
Resources
Learning Center
Upload
Plans & pricing Sign in
Sign Out

2012_Quit_Forest_Rally_MOTO_ENTRY_FORM_fillable_1_

VIEWS: 0 PAGES: 4

									         2012 Quit Forest Rally – 30 March to 1 April, 2012 – Busselton & Nannup, WA
Event Secretary: David Smith; 17 Virgilia Way, Forrestfield, WA 6058; Email – rally@wacarclub.com.au Mob 0419 894 555
                           Promoter: West Australian Car Club (Inc.) ABN: 22 710 686 402


                                              MOTO ENTRY FORM
1. Applicant Details
                             Team/Business Name                                    Surname:
Competitor/Entrant:          or Given Name:                                        (if applicable)

Address:

Suburb:                                                         State:                                 Postcode:

Phone - Hm:                                                     Mobile:

Phone - Wk:                                                     Fax:

Email:

MWA Licence No:                               Club Membership No.:                        ABN No (if applicable):

Sponsor (One only) If required to appear on entry
                                                       Name:
list in lieu of Competitor/Entrant


Rider Name:               Given Name:                                           Surname:

Address:

Suburb:                                                         State:                                 Postcode:

Phone - Hm:                                                     Mobile:

Phone - Wk:                                                     Fax:

Email:

Next of Kin on event:        Name:                                              Mobile:

MWA Licence No:                               Club Membership No:                          Riders Civil Licence No:


Team Manager:                                                  Mobile:
                                                               (during event)

Service Crew Chief:                                            Mobile:
                                                               (during event)

                                                                I do NOT have Ambulance Cover and agree to pay any costs
Ambulance Cover:              I HAVE Ambulance Cover    or
                                                                associated with Ambulance Transportation as a result of this event
2. Description Of Motorcycle
Competitor/Entrant:                                                                 Rider:

Make:                                                                              Model:

Registration No:                                                                   Capacity:

Motorcycle Stroke:                 mm

Base Colour:

Sign Writing & Colour:

3. Class – select ONE Class from the below

E1 – Up to 250cc                                                                     E2 – Over 250cc to 550cc
E3 – Over 550cc to Open                                                                 Q1 – Open cc 4 Stroke
                          All of the above vehicle details must be completed prior to submitting the entry form
Competitor/Entrant:                                                                                                    Rider:

2. PARTICIPANT DECLARATION CONTRACT TO PARTICIPATE
WARNING! THIS IS AN IMPORTANT DOCUMENT                            INDEMNITY AND RELEASE GIVEN TO ORGANISERS                          iii) may disclose my Information to third parties provided
WHICH AFFECTS YOUR LEGAL RIGHTS AND                               5. IN CONSIDERATION of the acceptance of me as a                   such disclosure is reasonably intended to be used for the
OBLIGATIONS, PLEASE READ IT CAREFULLY AND DO                      participant in the Meeting:                                        purpose of improving safety at events held by or in
NOT SIGN IT UNLESS YOU ARE SATISFIED YOU                          a) I AGREE TO INDEMNIFY AND KEEP INDEMNIFIED to                    conjunction with MA, or with an MA permit provided any
UNDERSTAND IT                                                     the full extent permitted by law the Indemnities and each of       such information is held by MA or my SCB in accordance
                                                                  them in the following manner:                                      with the MA Privacy Policy.
1. I THE UNDERSIGNED                                              i) that I participate in the meeting at my sole risk and           c) I irrevocably authorise MA and my SCB and hereby
                                                                  responsibility;                                                    appoint MA and my SCB as my lawful attorneys to collect
                                                                  ii) that I accept the Venue as it stands with all or any           from my Carers, and I hereby direct my Carers to provide to
                                                                  defects hidden or exposed;                                         MA or my SCB upon request being made by MA or my
HEREBY AGREE with Motorcycling Australia Limited                  iii) that I indemnify and hold harmless the Indemnities, their     SCB, any of my Information including but not limited to any
(“MA”) that I am by this agreement entitled to participate in     respective servants, agents, officials and competitors             information concerning any incident or event causing or
the motorcycle activity/meeting listed in Schedule 2              against any actions, costs, losses or claims which may be          contributing to or resulting from any injury, illness or death
(hereinafter called "the Meeting" or the “Event”) at the          made by me or on my behalf for or in respect of or arising         to me, the details of any diagnosis and prognosis provided
venue listed at Schedule 3 (hereinafter called "the Venue")       out of my death or any injury loss or damage caused to me          to me by my Carers (or any party with the knowledge of any
on the terms and conditions set out in this document.             or my equipment whether caused by negligence, breach of            of my Carers), and any other matter to the knowledge of my
                                                                  contract or in any other manner whatsoever.                        Carers that might reasonably be considered to be
DEFINITIONS                                                       b) I AGREE TO RELEASE to the full extent permitted by              requested by MA or my SCB for the purpose of improving
2. In this declaration:                                           law the Indemnities and each of them from all liability to me      safety at MA and SCB events.
a) “Claim” means and includes any action, suit, proceeding,       for any claim, loss, damage, cost or expense (whether
claim, demand, damage, cost or expense however arising            arising under statute, from negligence, personal injury,           POLICIES AND REGULATIONS
including but not limited to negligence but does not include      psychological trauma, death, property damage or                    12. I acknowledge, understand and agree that it is a
a claim against a Motorcycling Organisation under any right       infringement of third party rights or otherwise) that arises as    condition of my participation in the Event that I agree to be
expressly conferred by its constitution or regulation;            a result of any act, matter or thing done, permitted or            bound by, and subject to, the rules, regulations and
b) “Indemnities” means and includes the persons,                  omitted to be done by me or which is in any way connected          jurisdiction of MA as amended from time to time. Copies of
organisations and bodies corporate whose names appear             with my presence at or involvement in the Event.                   all MA rules, policies and regulations are available by
in Schedule 1.                                                    6. The release and indemnity provided by me in this                contacting the MA office.
c) “MA” means Motorcycling Australia Limited;                     declaration is in addition to, and will not in any way limit the   13. All participants are bound by the MA anti doping policy
d) “State Controlling Body” (SCB) means a state or territory      application of, the conditions of sale attaching to tickets,       and thus understand they may be subject to drug testing.
motorcycling association affiliated as a member of MA;            conditions of entry, conditions of credentials or any other        Testing conducted by the Australian Sports Anti-Doping
e) “Motorcycling Activities” means performing or                  applicable terms or conditions in respect of the Event.            Authority (ASADA) is in accordance with the ASADA Act
participating in any capacity in any authorised or                7. A term of this release and indemnity will not apply where       and the National Ant-Doping Scheme. This involves the
recognised Motorcycling Organisation event, meeting or            the term contravenes the law of the relevant jurisdiction          taking of a sample (any human biological fluid or tissue
activity;                                                         under which any legal action is legitimately taken however         whether alive or otherwise, or any human breath) for the
f) “Motorcycling Organisation” means and includes MA, and         such terms are severable and do not invalidate the                 purpose of detecting the use of a Prohibited Drug or Doping
the MA members (including the SCBs and affiliated clubs)          remaining terms.                                                   Method. Any participant infringing MA’s policy or refusing a
and where the context so permits, their respective directors,                                                                        drug test may be disqualified or otherwise dealt with in
officers, members, servants or agents.                            MEDICAL                                                            accordance with the terms of the anti-doping policy.
                                                                  8. I declare that I am and must continue to be medically
ACKNOWLEDGMENT OF RISKS, DANGERS &                                and physically fit and able to participate in the Meeting. I       EXECUTION
OBLIGATIONS                                                       will immediately notify MA in writing via my SCB of any            14. I THE UNDERSIGNED STATE THAT I HAVE READ
3. I ACKNOWLEDGE that:                                            change to my fitness and ability to participate. I understand      AND UNDERSTOOD THIS DECLARATION (INCLUDING
a) motorcycle sport is dangerous and that by engaging in          and accept the Indemnities will continue to rely upon this         THE WARNING, INDEMNITY AND RELEASE) AND
the sport (whether as a competitor, recreational rider,           declaration as evidence of my fitness and ability to               AGREE TO THE TERMS AND CONDITIONS AS STATED.
coach, official or media) at the Meeting I take and am            participate.
exposed to certain risks and dangers and am under certain         9. I acknowledge and agree that if required, the Indemnities       NAME (PRINT):
obligations as follows:                                           (or any of them) may arrange medical or hospital treatment
i) that I may be injured, physically or mentally, and may be      (including ambulance transportation) for me. I authorise
killed;                                                           such actions being taken by the Indemnities and agree to
ii) that my machinery or equipment may be damaged, lost           meet all costs associated with such action. I understand it        SIGNATURE:

                                                                                                                                     ………………….….…………... .DATE: ………….
or destroyed;                                                     is compulsory for me to have ambulance insurance in some
iii) that competitors may ride dangerously or with a lack of      form and I accept responsibility for the cost of ambulance
skill;                                                            transportation, ambulance cover and further agree to
iv) that track or event conditions may be hazardous and           maintain ambulance cover during the term of my license /           THIRD PARTY INDEMNITY WHERE PARTICIPANT IS
may vary without warning or predictability;                       membership.                                                        UNDER 18 YEARS OF AGE
v) that organisers, officials, landowners/track operators and
any agents or representatives of those in charge of               PRIVACY                                                            15. I/WE ……………………….………………..…………
meetings are frequently obliged to make decisions under           10. I hereby consent to the collection of my personal              being the parents or guardians of the person named in
pressure of time/or events;                                       information by the WA Trail & Enduro Motorcycle Club /             Clause 1 (hereinafter called "the entrant") HEREBY
vi) that any policy of insurance of or in respect of my life or   Western Australian Car Club, MA and the SCB in                     ACKNOWLEDGE:
physical or mental health may be voided;                          connection with my involvement at the Event and the use            a) I/we have read the whole of this document and
vii) that there may be no or inadequate facilities for            and disclosure of my personal information by WA Trail &            understand it;
treatment or transport of me if I am injured;                     Enduro Motorcycle Club / Western Australian Car Club,              b) I/we consent to the entrant participating in the Event;
vii) that I have an obligation to myself and to others to act     and MA to other agencies and officials associated with the         AND
safely and within the rules and regulations of MA;                Event for the purposes of conducting and managing the              c) I/we are aware of the risks, dangers and obligations set
b) the Indemnities do not make any warranty that the              Event. I understand that I may gain access to my personal          out in Clause 3 above;
services at the Meeting will be provided with due care and        information held by WA Trail & Enduro Motorcycle Club /            d) I/we acknowledge that the entrant is bound by and
skill or that any materials provided in connection with the       Western Australian Car Club by contacting WA Trail &               subject to the rules and policies of MA, including, without
services will be fit for the purpose for which they are           Enduro Motorcycle Club at PO Box 367, SUBIACO WA                   limitation, the MA anti-doping policy.
supplied;                                                         6904 or MA at 147 Montague St, South Melbourne,                    16. IN CONSIDERATION of the entrant being accepted as
c) to the extent that any warranty is implied it is excluded to   Victoria, 3205. I understand that if I do not provide the          a participant in the Meeting I/WE HEREBY INDEMNIFY
the full extent permitted by law;                                 personal information requested above that I may not be             AND RELEASE the Indemnities in the same manner and to
d) have voluntarily read and understood this warning and          permitted to participate in the Event.                             the same effect as if I/WE were the entrant and agree to
accept and assume the inherent risks in participating in the                                                                         personally accept all terms and conditions and obligations
Event.                                                            PERSONAL HEALTH INFORMATION                                        set out in this declaration,
                                                                  11. I hereby agree with MA and the SCB that in
WARNING UNDER THE FAIR TRADING ACT 1999 (VIC)                     consideration for my participation in the Event that MA and        PARENT/GUARDIAN (Insert Name)
4. Under the provisions of the Fair Trading Act 1999 (Vic)        the SCB may receive, collect, store and use personal
several conditions are implied into contracts for the supply      health information about me in the manner set out below:           ………………………………….…………….
of certain goods and services. These conditions mean that         a) I ACKNOWLEDGE that:
the supplier named on this form is required to ensure that        i) If I am injured, become ill or die at or following the Event    SIGNATURE
the recreational services it supplies to you are:                 the party listed at Item 8 in Schedule 1 in addition to any
- rendered with due care and skill;
- as fit for the purpose for which they are commonly bought
                                                                  hospital at which I am treated (together “my Carers”) will
                                                                  have health related information about me in their
                                                                                                                                     :…………..……………………..… DATE: ………..…
as it is reasonable to expect in the circumstances; and           possession, power and control relating to me which is
                                                                                                                                     SCHEDULE 1.
- reasonably fit for any particular purpose or might              subject to obligations imposed by the Privacy Act (“my
                                                                  Information”) and the Privacy Act is intended to protect my        1) Federation Internationale de Motocyclisme
reasonably be expected to achieve any result you have
                                                                  personal information;                                              2) Motorcycling Australia Ltd
made known to the supplier. Under section 32N of the Fair
                                                                  ii) MA and my SCB wish to collect my Information for               3) Motorcycling Western Australia
Trading Act 1999, the supplier is entitled to ask you to
                                                                  purposes that include their risk management programs,              4) WA Trail & Enduro Motorcycle Club
agree that these conditions do not apply to you. If you sign
                                                                  evaluating and improving the safety of MA and SCB events           5) Department of Conservation & Environment.
this form, you will be agreeing that your rights to sue the
                                                                  and of the Meeting organisers and facility providers of MA /       6) Western Australia Car Club.
supplier under the Fair Trading Act 1999 if you are killed or
                                                                  SCB permitted events, and generally to reduce the risks to         7) All other persons involved in the organisation, conduct
injured because the services were not rendered with due
                                                                  persons engaged in motorcycle sport; and                           and promotion of the Event or construction or location of
care and skill or they were not reasonably fit for their
                                                                  iii) It is reasonable for MA and my SCB to collect, store, use     the facilities used in connection with or otherwise related to
purpose, are excluded, restricted or modified in the way set
                                                                  and disclose my Information in accordance with clause              the Event
out in this form.
                                                                  11(a)(i) above and in the manner set out in clause 11(b).          8) Each of the respective officers, employees, servants,
NOTE: The change to your rights, as set out in this form,
                                                                  b) IN CONSIDERATION of my acceptance as an entrant in              agents, sponsors, successors and assignees of each of the
does not apply if your death or injury is due to gross
                                                                  the Meeting I consent and agree that MA and my SCB:                above.
negligence on the supplier's part. "Gross negligence" is
defined in the Fair Trading (Recreational Services)               i) may collect and store any of my Information, including
                                                                                                                                     SCHEDULE 2:
Regulations 2004. For the purposes of the clause 3, “the          obtain my Information from third parties including my
                                                                                                                                     Quit Forest Rally Moto
Supplier” shall mean and include the Indemnities.                 Carers;
                                                                  ii) may use any information collected in accordance with           31 March – 1 April, 2012
                                                                  this clause for any purpose consistent with creating safer
                                                                                                                                     SCHEDULE 3:
                                                                  competition in motorcycle sport and events held by or in
                                                                  conjunction with MA, my SCB, or with an MA or SCB                  Busselton, Nannup
                                                                  permit;
        2012 Quit Forest Rally – 30 March to 1 April, 2012 – Busselton & Nannup, WA
     Event Secretary: David Smith; 17 Virgilia Way, Forrestfield, WA 6058; Email – rally@wacarclub.com.au Mob 0419 894 555
                                      Promoter: West Australian Car Club (Inc.)          ABN: 22 710 686 402.




                                                         TAX INVOICE
                              This document will constitute a Tax Invoice for GST when fully completed and payment is made.


1. Applicant Details
Competitor/Entrant:                                                                  Rider:

2. Options Available
Item Description                                              No Required                     Each (inc GST)                  Total (inc GST)
0




Moto Entry Fee:
                                                                                                   $350                             $0
(with advertising proposed by the Organisers)
0




Dinner Tickets – Post Event Function                                                                $60                             $0
0




                                                                                                GRAND TOTAL (inc GST)               $0

3. Payment (please tick one box)
Electronic Funds Transfer :            Payment by EFT (preferred method)
                                              I have made an Electronic Funds Transfer to West Australian Car Club for the total amount payable
                                               above - $0
                                              BSB: 306 055
                                              Acct: 4197937
                                              Reference: please use Driver’s Surname as the reference
                                              Payment advice must be attached to entry form

Cheque :                               Payment by Cheque
                                              I enclose a cheque made payable to West Australian Car Club – Rally Account for the total amount
                                               payable above - $0.
                                              Cheque to be posted to
                                              Quit Forest Rally, 17 Virgilia Way, Forrestfield WA 6059

Credit Card Payment :               Payment by Credit Card:              Visa        Mastercard
                                              I authorise West Australian Car Club to debit my credit card for $0.00 representing the total amount
                                               payable above plus a 2% Credit Card surcharge.

                      Card No:

                        Expiry:                      CCV:                       Name on Card:

								
To top