INDEMNIFICATION DECLARATION by gqz18849

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									                                                                INDEMNIFICATION & DECLARATION
  This is to certify that I/We, the undersigned, submit this application to participate in the Christchurch Kart Club’s race and practice days (official and unofficial) at the Carrs Road
  Raceway and Ruapuna International Motor Raceway up until 30 June 2010.
  INDEMNIFICATION
  I/We acknowledge and agree to accept as a condition of membership that the FIA-CIK; MotorSport New Zealand;the Christchurch Kart Club; Christchurch City Council; the
  Canterbury Car Club; all sponsors and all or any members, officials and assistants of any of the above named and or known organisations, or their respective servants, officials,
  representatives, or agents shall not be under any liability whatsoever for the death or bodily injury, loss or damage, which may be sustained or incurred as a result of my/our
  participation in any event however such death or bodily injury, loss or damage is caused not withstanding that such death, injury loss or damage may have been contributed to or
  caused by negligence of the Christchurch Kart Club or Kartsport New Zealand or any of their respective officials, servants, representatives or agents or by any other person.
  Minors under 18 years, must have a parent’s or guardian’s signature approving conditions of entry and indemnity. Witness being the only person to represent minor at any judicial
  hearing.
  DECLARATION
  I/We give consent for the collection of the details below by the Christchurch Kart Club Inc. for the purpose of a membership record and for the Christchurch Kart Club Inc. to retain
  and disclose these to Kartsport New Zealand Inc, SPARC, funding agencies and sponsors.
  I/We acknowledge my/our right to access and correction of this information. This consent is given in accordance with the Privacy Act 1993.


PLEASE PRINT CLEARLY
                      Name                                      Age         Class (eg Cadet,                                  Signed                                               For        Official   Use
                                                            if under 18    JR, Junior, Senior)                                                                                  Date          Number     Receipt




DATE: _________________________________________                                                       EMAIL: ________________________________________________

ADDRESS: _____________________________________________________________________

CITY/TOWN:_______________________________________________________________ POSTAL ZONE:__________________

PHONE NUMBER: Home:_____________________________________ Cell/Business:________________________________

OCCUPATION:___________________________________________________________________________

SIGNATURE (parent or guardian if under 18 years):________________________________________________________(Proof of age required for
new application if under 18)
PLEASE INDICATE HERE BY CIRCLING WHICH KARTING YOU TAKE PART IN.                                                      ROAD                        SPRINT                      BOTH

Signature of financial Christchurch Kart Club member proposing NEW application:_____________________________Name: ___________________________

                                                                                                  Please tick this box if you would like to receive a copy of the Christchurch
Racing Fees                                                                                       Kart Club Minutes by email.
Family                                                                                            *A hard copy of minutes and newsletters can be made available to anyone
                                                                                                  unable to receive them via email if you wish, a small charge of $10 to cover
Social Fees
                                                                                                  the cost of printing, postage etc is unavoidable. Please tick the box and
Less Discount (where applicable)                                                                  complete the relevant section on your membership renewal if you are
Sub Total                                                                                         interested.
Joining Fee (where applicable)                                                                    If you are happy to have your contact details (ie name, address, email and
                                                                                                  phone numbers) circulated to all club members, please sign here.
Gate Key ($10 compulsory for all new members)
*Optional (admin, fee $10 for hard copy of minutes)                                               ---------------------------------------------------------------------------------------------------
                                                                                                  Please note by agreeing to this declaration the Christchurch Kart Club inc. will
                           TOTAL                                                                  not be responsible for any further distribution of your details.

                                                                                           Page 1
                       GENERAL INFORMATION FOR COMPLETING MEMBERSHIP FORM


NAME:                     First name followed by surname for everyone joining the club.
CLASS:                    Senior Racing (15 years and over)
                          Junior Racing (12 years and under 17)
                          Junior Restricted Racing (10 years and under 14)
                          Midget/Cadet Racing (6 years and under 12)
                          Social Member
AGE:                      A COPY OF THE APPLICANT’S BIRTH CERTIFICATE IS REQUIRED FOR ALL NEW MEMBERS IF
                          UNDER 18 YEARS.
PROPOSER:                 All new membership applications MUST be signed by a financial member of the Christchurch Kart
                          Club.

       FEES (Inclusive of GST).
       $50.00           JOINING FEE (New members only. The 1st member of a family pays this once only payment).
       $110.00          Senior Racing
       $80.00           Junior Racing (6 years and under 17)
       $35.00           Social
       $180.00          Family Membership*
       Discount of 10% for current financial members if paid by 30th June 2009.
       * Family membership is only available to immediate family members living at the same address.
       All names must be recoded on page 1 with normal signatures.
       Discount of 50% available for members aged 65 years and over.




 ACCOUNT SECTION:          The respective club fees are to be written on the lines opposite Racing, Family or Social.
                           There is NO DISCOUNT for new members.
 JOINING FEE:              This is paid by the first member of the family only.
 (for new members)
 BANK ACCOUNT DETAILS:              Bank ~ Westpac, Canterbury Centre.
 (For online payment)               Account Name ~ Christchurch Kart Club Inc
                                    Bank A/C # ~ 03 0802 0185318 00
                                    Please Ensure in the three reference boxes you include ;
                                    your name
                                    what payment is for ~ Membership
                                    type of payment ~ Family/Social/Junior etc




  Post to:          Secretary                                                            Any problems with your
                    336, West Belt                                                       application
                    Rangiora                                                             email coxylj@hotmail.com
                    7400                                                                 or phone Lynda on
                                                                                         03 313 1816
                                                             Page 2

								
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