APPLICATION FOR ONE DAY LICENCE £5.00
First Name: Surname:
Address:
Postcode:
Date of Birth: Home Number:
Email: Nationality:
Mobile Number: Evening Number:
Do you currently hold a recognised competition Licence?: Yes No
If Yes, please state the type of licence held:
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. Please give full details of any medication you are taking.
There is a Yes/No response required for each of the following questions:
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).
MOTOR SPORTS CAN BE DANGEROUS AND MAY INVOLVE INJURY OR DEATH
Read carefully before signing 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.
If the applicant is under 18 Please read and sign below:
I the parent or person with parental responsibility do declare that the information given above is correct and I have read and agree to the declaration as written.
Declaration to be signed at the event for which you are entering
Date:
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