APPLICATION FOR ONE DAY COMPETITION LICENCE

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I certify that the above statements are true and accurate and I understand my license may be invalid/withdrawn should any prove not to be so.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)

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