Clare Stages Rally 2017 Entry Form

 

IRDS/BRDS

Premium:

CLARE MOTOR CLUB

STAGES RALLY

SUNDAY 17th SEPTEMBER 2017

ENTRY FORM

 

DRIVER

FIRST NAME : .SURNAME :

 

ADDRESS:

 

 

 

TEL : (HOME) (MOBILE)

 

COMPETITION LICENCE NO: ISSUED BY:

 

IRDS/BRDS NUMBER:

 

NAVIGATOR

FIRST NAME : .SURNAME :

 

ADDRESS:

 

 

 

TEL : (HOME) (MOBILE)

 

COMPETITION LICENCE NO: ISSUED BY:

 

IRDS/BRDS NUMBER:

EMAIL ADDRESS FOR CREW:

 

 CAR DETAILS

YEAR OF MANUFACTURE : MAKE :

 

MODEL: REG NO :

 

CUBIC CAPACITY: CLASS ENTERED:

 

COMMERCIAL ENTRANT ( ONLY COMPLETE IF YOU HAVE A COMMERCIAL ENTRANT’S LICENCE)

 

NAME:

 

ADDRESS:

 

 

 

TEL : (HOME) (MOBILE)

 

ENTRANTS LIC NO: ISSUED BY : .

 

SERVICE VEHICLE

MAKE: MODEL:

 

REG NO: PERSON IN CHARGE:

 

AWARDS (PLEASE TICK)

CONNAUGHT MC CREW ( )BIRR MC CREW ( ) CLARE MC CREW ( ) GALWAY MC CREW ( ) LIMERICK MC CREW ( ) KERRY MC CREW ( )

Clare Motor Club Members only: Noel McCullagh Award ( ) Dermot Molloy Award ( )

SEEDING

 

WHO DO YOU THINK YOU SHOULD BE SEEDED NEAR?_

 

1-25 ( ) 26-50 ( ) 51-75 ( ) 76-100( ) 101+ ( )AT ORGANISERS DISCRETION ( ) PLEASE ENTER RESULTS BELOW ACHIEVED BY NOMINATED DRIVER 2016/2017

 

EVENT YEAR POSITION O/A

 

 

_

 

 

 

DECLARATION OF INDEMNITY

 

  1. I have read the supplementary regulations issued for this event and agree to be bound by them and by the General Competition Rules and Regulations of MI including the guidelines and regulations contained in Motorsport Ireland’s Code of Conduct for Children’s Sport. In consideration of the acceptance of this entry or of my being permitted to take part in this event I agree to save harmless and keep indemnified the Clare Motor Club (Organising Club), Clare County Council, Irish Automobile Club Ltd. t/a Royal Irish Automobile Club, Irish Motorsport Federation Ltd. t/a Motorsport Ireland and their respective officials, servants, representatives and agents from and against all actions, claims, costs, expenses and demands in respect of death, injury, loss of or damage to the person or property of myself, my driver(s), passenger(s) or mechanic(s) (as the case may be) howsoever caused arising out of or in connection with this entry or my taking part in this event and notwithstanding that the same may have been contributed to or occasioned by the negligence of the said bodies, their officials, servants, representatives or agents. Furthermore, in respect of any parts of this event on ground where Third Party Insurance is not required by law, this Agreement shall in addition to the parties named above extend to all and any other competitor(s) and their servants and agents and to all actions, claims, costs, expenses and demands in respect of loss of or damage to the person or property of myself, my driver(s), passenger(s) or mechanic(s).

 

My age (driver) is …………… (if applicable, state "over 18 years"). My age (co-driver) is …………… (if applicable, state "over 18 years").

  1. I declare that to the best of my belief the driver(s), passenger(s) possess the standard of competence necessary for an event of the type to which this entry relates and that the car entered is suitable and roadworthy for the event having regard to the course and the speeds which will be reached.

I declare that the use of the car hereby entered is covered by Insurance as required by the Road Traffic Act, which is valid for such part of this event as shall take place on roads as defined in the Act.

 

  1. I understand that should I at the time of this event be suffering from any disability whether permanent, temporary or otherwise which is likely to affect prejudicially my normal control of my automobile, I may not take part unless I have declared such disability to MI, who have, following such declaration issued a licence which permits me to do so.

 

  1. I undertake that at the time of the event to which this entry relates I shall be in possession of a current certificate of medical fitness. In the case of MI Licence Holders, only certificates on the official MI or FIA Medical Forms will be accepted.

 

  1. Any indemnity and/or declaration as prescribed by sub-paragraphs (a) and (b) above which is signed by a person under the age of 18 years shall be countersigned by that person’s parent or guardian, whose full names and address shall be given. Furthermore, the parents and/or guardians of persons under 18 years of age shall grant permission to MI and the Irish Sports Council to carry out tests in accordance with the Irish Anti-Doping Rules (Rule No 139) in the following form:

“I/We hereby grant permission to MI and the Irish Sports Council to carry out tests as set out in Rule No 139 of the GCRs in accordance with the Irish Anti-Doping Rules.”

 

  1. I agree to abide by and be bound by the Motorsport Ireland Social Media Policy of conduct as per Appendix 126 of the current MI Yearbook.

Who to contact in the event of a Serious Accident:

 

Name

Name

 

Address

Address

 

 

 

 

 

 

 

 

Phone Number (Home): Phone Number (Mobile):

 

Phone Number (Home): Phone Number (Mobile):

 

Relationship:

Relationship:

 

 

DRIVER CO-DRIVER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Signed Commercial Entrant: Date:

 

Signed Parent/Guardian:: Date:

 

Address:

 

 

Signed Driver: Date:

 

Signed Parent/Guardian: Date:

 

Address:

 

 

Signed Co Driver: Date:

 

Signed Parent/Guardian: Date:

 

Address:_

 

THE CLUB RESERVES THE RIGHT TO REFUSE ENTRY WITHOUT ASSIGNING A REASON.

Entry fee €795 Entry Fee for Main Field and Historics €525 plus €270 insurance levy, (Total €795) including Personal Accident Insurance and Standard IRDS Insurance. Juniors €300 plus €188 insurance levy (Total €488) including personal accident insurance and standard irds insurance. (NOTE EURO ONLY)

 

(PLEASE TICK) CHEQUE

CASH

M.O. DRAFT