Drivers/Entrants Name:______________________________________________ Comp.
Licence No ._____________
Address:______________________________________________ 4x4 Event Date:________________
Phone No. Home:___________________ Work:___________________ Mobile:______________
Fa x____________
Make & Model Of Vehicle:_____________ CC:______________ Petrol/Diesel
Class(e's):______________________
Next of Kin`s Name:________________________________________________ Phone
No ._____________________
Passengers Name:__________________________________________________ Phone No ._____________________
Passengers Address:________________________________________________
Entry Fee Enclosed:_____________________ Cheque/PO/Cash
INDEMNITY
“I have read the supplementary regulations for this event and agree to be
bound by them and the General Competition Rules of the RIAC/Motorsport Ireland
. In consideration of the acceptance of this entry or my being permitted to
take part in this event I agree to save harmless and keep indemnified the
COUNTY KILDARE MOTOR CLUB LTD and TIPPERARY LIGHT MOTOR CYCLE & CAR CLUB LTD, Coillte, the RIAC/Motorsport Ireland and their respective officials, servants,
representatives and agents, from and against all actions, claims, costs, expenses
and demands in respect of death, injury, loss or damage to the person or property
of myself, my driver(s), passenger(s), or mechanic(s) (as the case may be)
howsoever caused, arising out of, or in connection with this entry or my taking
part in this event and notwithstanding that the same may have been contributed
to, or occasioned by the negligence of said bodies, their officials, servants,
representatives or agents. Furthermore, in respect of any parts of this event
on ground where Third Party Insurance is not required by law, this agreement
shall in addition to the parties named above extend to all and any other competitor(s)
and their servants and agents and to all actions, claims, costs, expenses
and demands in respect of loss or damage to the person or property of myself.
my driver(s), passenger(s) or mechanic(s).
"I declare that to the best of my belief the driver(s) possess(es) the standard of competence necessary for an event of this type to which this entry relates and that the vehicle entered is suitable and road worthy for the event having regard to the course and the speeds which will be reached”
"I understand that should I at the time of this event be suffering from any disability whether permanent, temporary or otherwise which is likely to affect prejudicially my normal control of my vehicle I may not take part unless I have declared such disability to the RIAC/Motorsport Ireland who have, following such declaration issued a licence which permits me to do so (GCR108(C)).”
I understand that at the time of the event to which this entry relates 1 shall be in possession of a certificate of medical fitness made within the preceding twelve months.”
My Age is ___________________ ( If applicable state - over 18 years)
Signature (Driver):____________________________ Date _____________
Signature (Passenger):_________________________ Date _____________
Where the above is signed by a person under 18 years, the entry form shall
be countersigned by that person's parent or guardian, whose full name and
address shall be given.
Signature of Parent/Guardian:__________________________ Date:__________
Address:______________________________________________________________________
For Office use Only: Number:___________Cash/PO/Cheque: €__ _________Ins: Drive r_________________ Passenger ____________________