kerry Mini Stages 2017 Banna Entry Form

 

Kerry Motor Club

Mini Stages Rally ( 6 Stages)

Entry Form 2017

Comp No

 

 

 

 

 

Ref No

 

 

 

 

 

 

CREW

Driver

Co Driver

Commercial Entrant

Name

 

 

 

Address

 

 

 

 

 

 

 

Landline No

 

 

 

Mobile No

 

 

 

E-Mail

 

 

 

Licence No

 

 

 

Licence Type

 

 

 

Club

 

 

Only complete if you have a current 2017 COMMERCIAL ENTRANT LICENCE

Championships?

 

 

Correspondence to

Please tick

Please tick

SERVICE VEHICLE

VEHICLE INFORMATION

Make

 

Make

 

4WD

Please tick

Reg

 

Model

 

Turbo

Please tick

Person in Charge

Reg No

 

Your MC

 

 

Engine CC

 

Class Entered

 

Mob Ph No

PLEASE NOTE- To ensure correct seeding please give accurate results information

below and leave NO blank spaces.

Seeding Information

Please indicate driver’s performance over the last 3 years

Event

Status

Year

Start No

Type*

Overall

Class

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Entry Fee

* T = Tarmac / F = Forest

 

Rally Entry Fee - 411 plus €188 Insurance Levy

 

 

 

Completed in full with payment. Post to:

 

Michelle Walsh, 26 Casements View, Ardfert, Co Kerry. 0873165286

Calls after 6.30pm

 

 

 

 

 

 

Payment Please tick

Cheque

Post Order

Bank Draft

Cash

ALL CHEQUES: Kerry Motor Club Limited

TOTAL TO PAY

€599

Next of Kin Details, please include on day phone no…

Driver:

Co driver

 

 

 

 

 

Kerry Motor Club Limited

MINI STAGES RALLY

DECLARATION OF INDEMNITY.

 

(a) 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 Kerry Motor Club (Organising Club), 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").

 

(b) 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.

 

(c) 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.

 

(d) 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.

 

(e) 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.”

 

(f) 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.

 

 

Signature of Driver …………………………………………………… Date ……………………………….

Signature of Commercial Entrant …………………………………………… Date ……………………………….

 

Signature of Guardian or Parent

(if under 18 years of age)……………………………………………….…. Date ………….……………………

Address of Guardian or Parent …………………………………………………………….…………………………..

Signature of Co-Driver ……………………………………………………. Date …………..…..………………

Signature of Guardian or Parent

(if under 18 years of age)…………………………………………………… Date …………..………………….

Address of Guardian or Parent ………………………………………………………………………………………..