Full Licence 2010

SURNAME: …………………………………………...... FIRST NAME: …………………………………………………………

ADDRESS: …………………………………………………………………………………………………………………..…………….

………………………………………………………………………………………… POST CODE ………………………………….

DATE OF BIRTH: ………………………………………... PLACE OF BIRTH: …………………………………………………

1.      Have you been treated for, do you now have, or have you ever had any of the following:
(a) Head injury?                                                                                                   YES/NO*
(b) Respiratory problems or asthma?                                                                  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 complete further details below:
…………………………………………………………………………………………………………………………………………………………

2. Name and address of GP: ………………………………………………………………………………………………………………..

I authorise any hospital or medical practitioner to furnish information relative to my medical condition and history to 90 Racing MXC and/or Doodson Broking Group. I will abide by all competition rules and regulations of 90 Racing MXC. I understand that my licence may be invalid/withdrawn if I have made any statement which should prove to be inaccurate or untrue. I also understand that the licence issued to me may be withdrawn should I fail to abide by the rules and regulations of 90 Racing MXC. I sign to declare that I/my child will have the opportunity to inspect any track and its facilities before participating in any motorsport event. I/my child am familiar with motorsport racing and practising and fully understand the risk inherent therein. In consideration of the organisers allowing I/my child to take out a competition licence I hereby indemnify 90 Racing MXC and Doodson Broking Group and any other individuals/bodies connected to the event in respect of any claim made by I/my child in respect of injury or damage to my property howsoever caused including by their negligence and/or breach of any statutory duty arising from my/my child’s participation in any motorsport event.

Signature: ……………………………………………. Date: ……………………………………..

Signature of Parent/Guardian: …………………………..…………(if under 18 years of age)

Officials Signature: …………………………………… Position: …………………………………Date: ………………………

OFFICIAL USE ONLY:

Licence No:

Date:

Type:

Fee (£)

Authorised: