Application for One Day Licence
FULL
NAME:
……………………………………….......……...................................................
ADDRESS:
…………………………………………………………………………………………
………………………………………………………………
POST CODE:
………………
DATE OF BIRTH:
………………………………………...
MALE/FEMALE* delete as
appropriate
I wish to purchase a one event
competition license for the following event:
Event:
Motocross
Date
of Event: …………………………..
Organising Club:
90 Racing MXC
Venue:
…………………………………………………………………………………………………
Medical
Declaration
1.
Have you been rejected, or
accepted at increased premiums for life
insurance
on medical grounds?
YES/NO*
2.
Have you been treated for, do
you now have, or have you ever had
any
of the following:
(a) Head injury?
YES/NO*
(b) Unconsciousness or concussion (within the last 28 days)?
YES/NO*
(c) High blood pressure/heart disease or disorder?
YES/NO*
(d) Dizziness, fainting spells, epilepsy, fits or blackouts?
YES/NO*
(e) Disease, injury or operation to either eye?
YES/NO*
(f) Do you have any vision defect or loss of sight in either eye?
YES/NO*
(g) Do you have any condition which affects movement of arms or legs?
YES/NO*
(h) Do you have any false or missing limbs?
YES/NO*
* If you have answered YES to any
of the above, please give further details:
…………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………
I
certify that the above statements are true and accurate and I understand
my license may be invalid/withdrawn should any prove not to be so.
I
also authorise any hospital or medical practitioner to furnish information
relative to my medical condition to ORPA.
Signature:
……………………………………………………..……... Date:
…………………………
Signature
of Parent/Guardian:
………………………………..………(if
under 18 years of age)
