BAJA RALLY APPLICATION FORM OCT 9 - 14, 2017
1) This form is not valid without a deposit at the time of application and will be discarded within 24 hours.
2) Rider/ Driver forfeits any priority or benefits associated with priority if this form is submitted without payment.
3) Riders/ Drivers must be truthful and accurate in their responses.
4) Any material misrepresentations on this application will be grounds for disqualification from the BAJA RALLY.
5) Applicants may not apply to enter any BAJA RALLY Classes without prior roadbook navigation experience and competitive motorcycle experience.
6) The organizer may exclude any applicant it believes is not qualified to participate, or for any other reason.
7) Applicants must provide their individual or group plan health insurance information or attest they are uninsured at time of application and must be re-confirmed before the event.
8) BAJA RALLY, LLC WILL NOT SHARE YOUR INFORMATION WITH ANYONE EXCEPT AS NEEDED BY MEDICAL
PROFESSIONALS IN THE EVENT OF AN EMERGENCY DURING THE BAJA RALLY.
9) ADV EXPERT classes require applicants to submit a resume and/ or curriculum vitae demonstrating experience in both roadbook rallies and racing in their respective discipline. This is process is simple and involves a short letter to admin@bajarallymoto.com requesting an entry with a listing of relevant racing and rally experience.
10) Your application is not considered accepted until the applicant has received an email confirmation from admin@bajarallymoto.com
Email address *
I am a 2016 EU-based entrant who was affected by the freight shipping delay and entering the BAJA RALLY 2017 on a complimentary basis because I received the free offer to do so: *
2017 BAJA RALLY APPLICATION FORM: OCT 9 - 14, 2017
PERSONAL INFORMATION
This is required information about you and will not be released or shared with anyone other than your named emergency contact and/or medical personnel in the event of an emergency. By submitting this form you are consenting to BAJA RALLY sharing this information in such a manner, for your benefit.
First Name *
As will appear on the entrants list
Last Name *
As will appear on the entrants list
Street Address *
PO Box is NOT acceptable
City *
State *
Zip Code *
Country *
Phone Number *
Include country and regional dialing codes
Email address *
Emergency Contact Name *
Emergency Contact Phone *
Passport Number *
Full Legal Name *
As appears on your Passport
Date of Birth *
MM
/
DD
/
YYYY
Passport Issuing Country *
Passport Expiration Date *
MM
/
DD
/
YYYY
Who Referred You To Enter?
If a racer who has entered is named here, they will receive a discount or credit for referring you
Are you covered by a health insurance policy? *
You want us to know this information in the event of an emergency
Health Insurance Company Name
Health Insurance Policy Number (ID number)
Health Insurance Policy Group Number
Existing Medical Conditions
List All
Blood Type *
Allergies *
List All
What is your level of expertise in off-road motorcycle riding/ racing *
First time racers will and beginners are excluded from BAJA RALLY PRO CLASS & RALLY 1 EXPERT CLASS
Have you participated in a "road book-navigation" style rally or similar "road book training"? *
Have you participated in a competitive motorcycle event (ie race)? *
Jersey Size *
BAJA RALLY may issue entrants a personalized jersey with your name and number.
CLASSIFICATION
In What Class Will You Apply To Enter? *
See the classification criteria in Section 1.5 of the RULEBOOK under the "2016" tab on www.bajarallymoto.com
MOTORCYCLE / VEHICLE
Year *
Make *
Model *
Type *
Does your motorcycle /vehicle have an electronically powered road book reader? *
Does your motorcycle / vehicle have an electronically powered odometer? *
What's your vehicle's motor displacement (CC) *
How big is the engine in cubic centimeters
What is the approximate range (miles) of your motorcycle on a full tank of gas *
Riders will need approximately 100 miles of minimum range to participate in the BAJA RALLY
RALLY COMP, SAT PHONE & SPOT REQUIREMENTS
I am fully aware that I must comply with the RALLY COMP technical requirement and arrive to registration and technical inspection prepared for installation of the RALLY COMP unit., *
Details of the RALLY COMP Requirement are available on the BAJA RALLY website at www.bajarallymoto.com
I am fully aware that I must comply with the SATELLITE PHONE REQUIREMENT and that I must have a properly registered and functioning satellite phone in order to pass the technical inspection at registration. *
Details of the SAT PHONE Requirement are available on the BAJA RALLY website at www.bajarallymoto.com
Which answer best describes how you will comply with the Sat Phone Requirement? *
Sat Modo is the Official Sat Phone Provider to the BAJA RALLY and has convenient and economical means for riders to comply with the Sat Phone Requirement
I am fully aware that I must have a SPOT Tracker or equivalent Delorme unit that is fully activated with tracking feature and configured to BAJA RALLY specifications *
Details of the SPOT Requirement are available on the BAJA RALLY website at www.bajarallymoto.com
What type SPOT Tracker will you bring to the BAJA RALLY *
You must have an acvivatred SPOT Tracker or equivalent Delorme unit registered and configured to BAJA RALLY specification before arriving to on-site registration and technical inspection.
RELEASE, WAIVER & INDEMNIFICATION
Please be advised that by submitting this form and/or making any payment to BAJA RALLY and/or BAJA RALLY LLC, you are acknowledging that motorcycle & UTV riding and racing is inherently dangerous and participating in an off-road rally is especially hazardous and potentially perilous. Prior to participating in the BAJA RALLY, you hereby release Darren Scott Bloom, BAJA RALLY, BAJA RALLY LLC, its principals, organizers, staff, volunteers, partners and sponsors from any liability whatsoever, financial or otherwise, if you are injured or killed during, or as a result of, your participation, in the BAJA RALLY. You acknowledge that you will further be subject to reading, understanding and signing multiple additional waivers and releases of liabilities which further indemnify Darren Scott Bloom, BAJA RALLY, BAJA RALLY LLC, its principals, organizers, staff, volunteers, partners and sponsors from any and all liability if you sustain property damage or are injured or killed during, or as a result of, your participation in the BAJA RALLY, whether it is caused by an accident or by the gross negligence of Darren Scott Bloom, BAJA RALLY, BAJA RALLY LLC, its principals, organizers, staff, volunteers, partners and sponsors.

I hereby give up all my rights to sue or make a claim for damages due to negligence or any other reason whatsoever against BAJA RALLY LLC, Darren Scott Bloom, their staffs, affiliates, members, promoters, sponsors and all other persons, participants or organizations conducting or connected with this event for injury to property or person that I may suffer, including crippling injury or death, while participating in the event and while upon the event premises.

I know the risks of danger to myself and my property while preparing for and participating in the event and while upon the event premises and, relying on my own judgment, skill and ability, I assume all such risks of loss and hereby agree to reimburse all costs to those persons or organizations connected with this event for damages incurred as a result of my negligence.

I understand that there is no insurance to claim against if I am injured or killed in this event. I understand that any insurance for BAJA RALLY LLC, Darren Scott Bloom, their staffs, affiliates, members, promoters, sponsors and all other persons, participants or organizations conducting or connected with this event, provides coverage if a spectator or property owner makes a claim against BAJA RALLY LLC, Darren Scott Bloom and/or our affiliates. I understand that the policy clearly excludes any and all liability claims that could conceivably by made by people like me who are actually participating in this event.


Your application to participate in the BAJA RALLY can be denied for any reason. A full refund of your registration fee of deposit will be returned to the applicant if the application is declined during this 30 day period.

Have you read and do you understand the RELEASE, WAIVER & INDEMNIFICATION statement above? *
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