TYPE: Adult Youth Dual Adult/Youth

2012 MCF Competition Licence Application Form

Complete this form in BLOCK CAPITALS to apply for an MCF Competition Licence.  If you require assistance filling in this form, please contact the MCF Office on: 01865 343666. 

A PASSPORT SIZED PHOTOGRAPH IS REQUIRED FOR ALL FIRST TIME APPLICATIONS AND FOR YOUTH RIDERS A COPY OF YOUR BIRTH CERTIFICATE OR PASSPORT IS ALSO REQUIRED.

Section 1 - Your Details

RIDERS FIRST NAME: RIDERS SURNAME:

DATE OF BIRTH: PARENTS NAME:

HOUSE NAME/NUMBER: ADDRESS 1:

ADDRESS 2:    TOWN:

COUNTY:       POST CODE:  

EMAIL ADDRESS:

MOBILE NUMBER 1: MOBILE NUMBER 2:

HOME TEL NO: OCCUPATION:

MAKE OF MACHINE: ENGINE CAPACITY:

MODEL: YEAR:

2 STROKE/4STROKE: 2 STROKE 4 STROKE TRANSPONDER NO (IF HAVE OWN):

DO YOU CURRENTLY HOLD A RECOGNISED COMPETITION LICENCE?:          YES NO

IF YES, PLEASE STATE THE TYPE OF LICENCE HELD:

HOW MANY YEARS RACING EXPERIENCE DO YOU HAVE?:

WHICH MCF CLUB ARE YOU A MEMBER OF?:   90 RACING MXC

You MUST be a member of an MCF affiliated club to apply for a 2012 MCFederation Licence.

PLEASE NOTE THAT THE CLUB WITH WHICH YOU SUBMIT YOUR LICENCE APPLICATION WILL BE THE CLUB THAT YOU WILL REPRESENT FOR THE ELITE YOUTH LEAGUE IF APPLICABLE IN 2012

Section 2 - Medical Information

• Please answer all the questions truthfully.
• A false declaration may have serious consequences.
• If you answer 'Yes' to any of the questions please give full details in the space provided at the end of this section. This should include the date you first developed the condition, details of any tests, investigations and of any treatment you have undergone.
• Please include the names and addresses of any specialists you have seen and hospitals you have attended.

1.      Have you been treated for, do you now have, or have you ever had any of the following:

(a) Epilepsy, fits, blackouts or any condition which may cause loss of consciousness?                   Yes No                              

(b) Any condition that might cause dizziness, vertigo or loss of balance?                        Yes No

(c) Have you been unconscious because of a head injury or suffered from concussion?                Yes No

(d) Any brain disorder such as a stroke, MS or Motor Neurone disease?                        Yes No

(e) Any loss of strength, feeling, control or movement of any of your limbs, head or neck?               Yes No

(f) Amputation of any part of your limbs with or without an artificial replacement?             Yes No

(g) Any condition or operation involving your heart or main blood vessels or any high blood pressure?   Yes No

(h) Any kind of tumour or cancer?                                                                              Yes No

(i) Diabetes? If 'Yes' please state whether treated by diet, tablets or insulin? Yes No

(j) Any psychiatric or emotional illness or any alcohol/drug/substance misuse?               Yes No

(k) Any condition affecting your vision or eyes, including colour blindness?                           Yes No

(l) Are you taking any medication?  (Include all tablets, medicines etc. whether prescribed or            Yes No

bought over the counter).

Please use the space below to give further details if you have answered “Yes” to any of the above questions:

Section 3 - Licence Required & Cost

Please tick box for the relevant licence required:

Motocross:

Yes No Auto - £25.00   Yes No Adult Junior - £30.00  Yes No Youth Minibike 50 - £25.00

Yes No 65cc - £25.00   Yes No Adult Expert - £30.00  Yes No Youth Minibike 110 - £25.00

Yes No SW85 - £25.00  Yes No Adult Quad - £30.00    Yes No Youth Minibike 140 - £25.00

Yes No BW85 - £25.00  Yes No Youth Quad - £25.00   Yes Np Adult Minibike - £30.00

Yes No Rookies - £25.00 Yes No Rookies/Adult Dual - £30.00

(Rookies = Youth Open)

*Youth Rookies please state Adult Expert or Junior status for your Adult Licence if you require a joint Rookie/Adult licence

**For all Adult Cross Country classes other than Pro or Expert

Payment  

• PLEASE MAKE CHEQUES PAYABLE TO: MC Federation Ltd
• PAY CASH AT A 90 RACING MXC MEETING BUT PLEASE ENSURE YOU HAVE FULLY COMPLETED EVERY ASPECT OF THE FORM

MOTOR SPORTS CAN BE DANGEROUS

AND MAY INVOLVE INJURY OR DEATH

Read carefully to ensure you agree.

1. The answers given by me in this Licence application are true.
2. I fully understand the type of the events which the Licence allows me to enter and the rules and regulations that apply to such events and to competitors and will comply with them.
3. I will ensure that before I enter any event I am competent to compete and that any vehicle that I use is safe and fit for the competition and nature of the course.
4. I will satisfy myself (by sighting lap or otherwise) before taking part that the venue and track is acceptable to me with regard to its features and physical layout (unless prohibited to do so).
5. I will NOT enter or take part in any competition where I have a doubt as to my safety.
6. I will tell you immediately if, for any reason, I believe that I am no longer able to satisfy the terms of this Licence or I become aware that I have become unable to compete due to physical or other disability.
7. I agree to accept the risks of injury and death that are inherent in motor sports and agree to take part at my own risk.
8. If under the age of 18, my parent / guardian has read the above and signed the declaration and agreement below.

PARENT/GUARDIAN DECLARATION AND AGREEMENT (if under 18)

You must read the answers given by the applicant and agree to the terms below which create obligations on you before a Licence can be issued.

        a)     I am the Parent/Legal guardian of

b)    I have read the application for a competition Licence completed by him/her, and confirm the truth of his/her answers.

c)     I confirm that he/she is competent to compete in motor sport events permitted by the Licence applied for and that both he/she and I are aware of the dangers.

d)    I will ensure that he/she complies with the declaration signed by him/her and will satisfy myself as to the safety of his/her machine and the safety of the venue before allowing him/her to take part.

e)     I also hereby AGREE that in consideration of you granting a Licence that if the applicant should sustain any injury from any cause whilst taking part in a competition and as a result bring a claim for compensation against you or the organisers or officials or sponsors or entrants or owners of the venue I WILL INDEMNIFY AND PAY BACK TO YOU any sum which you may be required to pay as a result of such claim.

A PASSPORT SIZED PHOTOGRAPH IS REQUIRED FOR ALL FIRST TIME APPLICATIONS AND FOR YOUTH RIDERS A COPY OF YOUR BIRTH CERTIFICATE OR PASSPORT IS ALSO REQUIRED.

MCFederation

Dovecote, Little Baldon Farm, Little Baldon, Oxford OX44 9PU

T: 01865 343666 & F: 01865 340014