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Round 3 - Heidelberg Enduro (17 June 2017)
Email address
Email address for correspondence
Your answer
Rider's Full Name
Full name
Your answer
Confirm Race Date
Province and Club
Enter Province in which you reside and club for which you ride
Your answer
Contact Cell number
The telephone number to contact rider or parent on
Your answer
Date of Birth (format: 1 Jan 2006)
Your answer
Riders Blood Group
Enter Riders Blood Group
Enter Allergy if any - n/a if none
Your answer
Emergency Contact
Name of Person to contact in an Emergency
Your answer
Emergency Person contact Number
Number of person to contact in an emergency
Your answer
Rider Class
What Class are you Riding in: (85cc class includes 105cc) (High school class includes 125cc, 200cc & 200 4T)
Bike Number (on the bike on race day)
Your answer
Licence (WOW / MSA / Other
Race Licence Number
race licence
Your answer
Bike - make, model and engine capacity
What make of Bike are you riding - all details please
Your answer
UNDERTAKING: I have read, understand and agree to comply with the GCR's, SSR's and SR's, and am familiar with all the rules and penalties pertaining to this event and agree that my entry, bike, protective clothing, fuel containers, environmental mat and fire extinguisher all comply with MSA requirements. I and my crew/supporters agree to the NO SMOKING, NO ALCOHOL and NO FIRES in the pit area rule and undertake to keep our pit area clean and remove all rubbish and containers when leaving. I also understand the implications of 'Responsibility of Competitor' per the above regulations. DRUG FREE DECLARATION: I hereby confirm that I am familiar with the schedule of prohibited drugs/ performance enhancing substances as released by MSA from time to time and that I am aware of the requirement for random drug testing. I confirm that I have not participated in the use of any of these substances.
Rider undertakes to advise race organisers of any medication racer is taking, or of any recent procedure or current medical situation of racer.
Account name: T Bone Racing
FNB Tableview
Branch code: 203809
Account number: 62584641635


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