Blackhills Autocross Entry Form
63 Car Club (Elgin) LTD
Declaration
‘Held under the General Regulations of The Motor Sports Association (incorporating the provisions of the International Sporting Code of the FIA) and these Supplementary Regulations.’
I declare that I have been given the opportunity to read the General Regulations of the Motor Sports Association and, if any, the Supplementary Regulations for this event and agree to be bound by them. I declare that I am physically and mentally fit to take part in the event and I am competent to do so. I acknowledge that I understand the nature and type of the competition and the potential risk inherent with motor sport and agree to accept that risk.

‘I understand that motorsport can be dangerous and accidents causing death, injury, disability and property damage can and do happen. I understand that these risks may give rise to my suffering personal injury or other loss and I acknowledge and accept these risks. In consideration of the acceptance of
this entry I agree that neither any one of or any combination of the MSA and its associated clubs, the organisers, the track owners or other occupiers, the promoters and their respective officers, servants, representatives and agents (the “Parties”) shall have any liability for loss or damage which may be
sustained or incurred by me as a result of participation in the Event including but not limited to damage to property, economic loss, consequential loss or financial loss howsoever caused. Nothing in this clause is intended to or shall be deemed to
exclude or limit liability for death or personal injury. To the fullest extent permitted by law I agree to indemnify and hold harmless each of the Parties in respect of any loss or damage whatsoever and howsoever arising from my participation in this event.
'I declare that to the best of my belief the driver(s) possess(es) the standard of competence necessary for an event of the type to which this entry relates and that the vehicle entered is suitable and roadworthy for the event having regard to the course and the speeds which will be reached'.
State your age if you are under 18 . . .
If I am the Parent or Guardian of the driver ‘I understand that I shall have the right to be present during any procedure being carried out under the Supplementary Regulations issued for this event and the General Regulations of the MSA.’ As the Parent/Guardian ‘I Confirm that I have acquainted myself and the minor with the MSA General Regulations, agree to pay any appropriate charges and fees pursuant to those Regulations (to include any appendices thereto) and hereby agree to be bound by those Regulations and submit myself without reserve to the consequences resulting from those Regulations (and any subsequent alteration thereof). Further, I agree to pay as liquidated damages any fines imposed upon me up to the maxima set out in Part 3, Appendix 1.’
Where the Parent is not present there must be a Guardian who must produce a written and signed authorisation from the Parent/Guardian to act as their representative.

‘I undertake that at the time of the event to which this entry relates I shall have passed or am exempt from an ASN specified medical examination within the specified period.’ (H.10.1.6).

‘I have read and fully understood the Procedure for Control of Drugs and Alcohol as contained in the Competitors’ and Officials’ Yearbook Regulations H39, D35.1, G15.1.4 and have also fully familiarised myself with the information on the web sites referred to (www.ukad.org.uk and www.wada-ama.org) in particular the UK Anti Doping Rules which have been adopted by the MSA. Further, if I am counter-signing as the Parent or Guardian of a minor then in addition to the deemed consent to the testing of that minor (UKAD Code Art 5.6.2) I hereby confirm that I give
such consent for the minor concerned to be so tested.’

‘I hereby agree to abide by the MSA Safeguarding Policy and Guidelines and the National Sporting Code of Conduct.’

By Submitting my Completed Entry Form I agree to the above statements.

Name *
Your answer
Address
Your answer
Telephone Number
Your answer
Email Address *
Your answer
Competition Licence Number
Your answer
Type of Licence
Your answer
Car Club
Your answer
Car Make and Model
Your answer
Engine Capacity
Your answer
Shared Car
Class Entered
Next of Kin Name
Your answer
Address (if Different)
Your answer
Telephone Number
Your answer
Payment
Payment : Entry Fee £75.00
Cheque payable to The 63 Car Club (Elgin) LTD
Paypal to www.paypal.me/dittle83
Thank You for your Entry!
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