TOPCAR Activity Form

Activity Entry - TOPCAR

Please choose which TOPCAR activity you will be entering and fill out all of the form.

You can save and continue later at anytime should you need to get more information.

Entrant and Driver information must be completed if they are seperate persons.

Step 1 of 6

CIRCUIT: CARCO.com.au Raceway

EVENT(Required)

Please choose which event you will be entering

Entrant Information

Entrant Name(Required)

First Last

Entrant Date of Birth(Required)

Entrant Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Entrant Email(Required)

Entrant Phone(Required)

Entrant Emergency Contact Name(Required)

First Last

Entrant Emergency Contact Phone(Required)

Entrant Motorsport Australia ID

Driver Information

Is the Driver the same as the Entrant?(Required)

Driver Name(Required)

First Last

Driver Date of Birth(Required)

Driver Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Driver Email(Required)

Driver Phone(Required)

Driver Emergency Contact Name(Required)

First Last

Driver Emergency Contact Phone(Required)

Driver Motorsport Australia ID

Entrant Information

I being the competitor entrant/s of the Automobile described on this Entry Form wish to enter that Automobile for the above Activity. Being legally authorised to enter the car described on this form, I hereby declare that the Automobile and all related equipment and components necessary for participation in this event must be presented, at all times in every respect, in a condition suitable for use in this Activity, and that I have caused the Automobile to be inspected according to a maintenance schedule which I have developed and that it is free from mechanical defect, be they of preparation or structural integrity, that may render the Automobile unsafe for the proposed Activity.

Driver Information

I being the named Driver of the Automobile described on this form hereby declare that I have been fully briefed by the entrant on all aspects of operation of the Automobile, including peculiarities relating to its handling and performance during an Activity; and I have satisfied myself that the Automobile is safe and suitable for the intended Activity; and that my Activity apparel, including helmet and any HANS device (where required) is in compliance with Schedule D of the Motorsport Australia Manual.

Fit and Proper Person

I acknowledge and agree that it is a fundamental condition of issue of this licence and its continuing validity that I: 1. have advised Motorsport Australia in writing of any act, omission, fact or circumstance which may affect my ability to be and remain a fit and proper person to hold this licence and exercise the duties and privileges that relate to it; 2. have advised Motorsport Australia in writing if I have been found guilty of or charged with any: a. serious indictable criminal offence; or b. sexual offence, (unless this is a ‘spent’ or ‘annulled’1 conviction); and 3. undertake to advise Motorsport Australia immediately in writing upon any court of competent jurisdiction making any such finding, or upon being charged with any such offence. I acknowledge and agree that Motorsport Australia may, in its absolute discretion (subject to this clause) refuse to issue, suspend or withdraw this licence at any time should Motorsport Australia reasonably form the view that I may not be, or am not, a fit and proper person to be granted or hold this licence and/or exercise any of the duties and/or privileges that arise from, or relate, to it, however I understand that before a licence is refused, suspended or withdrawn by Motorsport Australia I will be afforded the opportunity to address the Motorsport Australia Board in writing on the proposed refusal, suspension or withdrawal. 1 As determined by the Crimes Act 1914 (Cth), Criminal Records Act 1991 (NSW), Criminal Law (Rehabilitation of Offenders) Act 1986 (Qld), Spent Convictions Act 2000 (ACT), Criminal Records (Spent Convictions) Act 1992 (NT), Spent Convictions Act 1988 (WA) and/or the Annulled Convictions Act 2003 (Tas) (including their successors and replacements.)

Declaration

ANY APPLICANT MAKING A FALSE DECLARATION IS LIABLE TO REFUSAL AND CANCELLATION OF INSURANCE COVER I/We being the competitor Entrant and/or Driver, certify that the particulars in this entry form are true and correct in every particular, to the best of my/our knowledge and belief and will advise Motorsport Australia immediately if any of the information I have given is no longer true and correct. I/we declare that I/we have read and understood the Motorsport Australia Risk Management Conditions issued for the event, and agree to be bound by them and the provisions of the NCR of Motorsport Australia I/We being the competitor Entrant and/or Driver, certify that the Automobile described on this Entry Form complies with Schedule A and B of the NCR of Motorsport Australia. I/We accept the conditions of, and acknowledge the risks arising from, attending or participating in Motorsport Activities being provided by Motorsport Australia and the Entities. I/We agree to be bound by the rules, regulations and policies of Motorsport Australia at all times as a condition of participating in this activity. I/We have read, understood, acknowledge and agree to the above including the exclusion of statutory guarantees, warning, assumption of risk, release and indemnity.

Entrant Name(Required)

Driver Name(Required)

Entrant Signature(Required)

Driver Signature(Required)

Date Agreed To by Entrant(Required)

Date Agreed To by Driver(Required)

Is the Entrant and/or Driver Under 18 years of age?(Required)

Parent / Guardian Consent (must be completed for all applicants under 18 years of age

Parent / Guardian Name(Required)

First Last

Parent / Guardian E-Mail(Required)

Parent / Guardian Phone(Required)

Parent / Guardian Date of Birth(Required)

Parent / Guardian Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

I am the parent/guardian (please choose)(Required)

Parent / Guardian Signature(Required)

Your Privacy

Motorsport Australia requires the above information to assess your suitability for Motorsport Activities. The information provided by you may be used and disclosed to others by Motorsport Australia for the purposes of Motorsport Australia’s business. Motorsport Australia may not be able to permit you to undertake the Motorsport Activities if you do not provide all of the information requested above. Full details of Motorsport Australia’s Privacy Policy (including how you can access and correct your personal information and make a complaint) are available at Motorsport Australia’s website (motorsport.org.au). In the event that you suffer from any injury, sickness or death during any Motorsport Activities you consent to the release by health services of your personal health information to an authorised representative of Motorsport Australia who may use it in the preparation and release of accident or incident information and reports to interested parties for the purposes of accident investigation, accident prevention and safety activities or for the purposes of processing insurance claims. Motorsport Australia and its partners may send you direct marketing materials from time to time. This is in addition to relevant information which Motorsport Australia may send to you as part of Motorsport Australia’s services.

Name

This field is for validation purposes and should be left unchanged.