2012 MSA British Rallycross Championship 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 SECTION 1 - DRIVER DETAILS DRIVER NAME * DATE OF BIRTH * DRIVER ADDRESS * HOME TOWN * ZIP CODE * E-MAIL ADDRESS * PHONE * LICENCE NO. * LICENCE GRADE ASN CLUB MEM NO. Please indicate below any prescribed drugs or conditions which should be notified to the Medical Team SECTION 2 - VEHICLE DETAILS CLASS * MSA SUPER CAR MSA SUPERNATIONAL SUPER 1600 HOTHATCH SUZUKI SWIFT SUZUKI SWIFT JUNIOR BMW MINI RX150 BTRDA StockHatch BTRDA SuperModified MDA-BTRDA Minicross Historic Rally Cars Rallycross Pre 1982 Rallycross 1982 - 1987 CAR NUMBER * Make of car * TYPE / MODEL * TRANSPONDER NO. * CC FORCED INDUCTION ? SPONSOR DETAILS SECTION 3 - EVENT DETAILS ENTRY CLOSING DATE IS 2 WEEKS PRIOR THE EVENT, LATE ENTRIES WILL AUTOMATICALLY INCUR A £ 25 LATE ENTRY FEE. SELECT AT LEAST 1 EVENT. ENTRY FEE CLUBMANS ENTRY FEE Sunday July 22 Mallory Park £ 235,- £ 215,- Sunday/Monday August 26 & 27 Lydden Hill £ 235,- £ 215,- Sunday October 07 Pembrey £ 235,- £ 215,- Sunday October 28 Croft £ 235,- £ 215,- 1: 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 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 fC I understand that should I at the time of this event be suffering from any disability whether permanent or temporary 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 ASN which has, following such declaration, issued a licence which permits me to do so. : If I am the Parent/Guardian/Guarantor 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/Guarantor I confirm that I have acquainted myself 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 DRIVER SIGNATURE :   DATE : AGE IF UNDER 18 :       Any indemnity and/or declaration as described by the paragraphs above which is signed by a person under the age of 18 shall be countersigned by that person’s parents or guardian, whose full name & address is below NAME OF PARENT / GUARDIAN :   SIGNATURE PARENT / GUARDIAN : FULL ADDRESS :       SECTION 4 - NEXT OF KIN Name and Address of Relative to be Notified in the Event of a Serious Accident NAME : *   RELATIONSHIP : * ADDRESS : *   PHONE : * SECTION 5 - ENTRANT DETAILS Please only complete this section if a valid Entrants Licence has been issued by your ASN. If no details are entered below, the 1st Driver will be nominated as the Entrant in accordance with MSA Regulation. ENTRANT NAME : *   ENTRANT ADDRESS : * ENTRANT POSTCODE : *   ENTRANT LICENCE NO. : * ENTRANT E-MAIL ADDRESS : *   PHONE : REPRESENTATIVE NAME :   ASN : 1: 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 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 fC I understand that should I at the time of this event be suffering from any disability whether permanent or temporary 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 ASN which has, following such declaration, issued a licence which permits me to do so. : If I am the Parent/Guardian/Guarantor 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/Guarantor I confirm that I have acquainted myself 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 ENTRANT SIGNATURE :   DATE : AGE IF UNDER 18 :       Any indemnity and/or declaration as described by the paragraphs above which is signed by a person under the age of 18 shall be countersigned by that person’s parents or guardian, whose full name & address is below NAME OF PARENT / GUARDIAN :   SIGNATURE PARENT / GUARDIAN : FULL ADDRESS :