500CC - KhanaKids Multi Occupant Vehicle Declaration

Rally / Off Road Crews and Official Vehicles with more than one occupant

This form is to provide necessary information to ensure that persons in close contact, by sharing a vehicle cockpit space, have provided an assessment of their current health status in regard to COVID-19 conditions. It will permit those persons to participate as a crew in an event or to carry out official duties at an event. This form is an addition to any other requirements for entry or participation in an event, including the completion of any other Disclaimer.

This form is to be completed by:
• each crew member in a Rally or Off Road vehicle competing at an event; and
• each person who will share a vehicle for official duties at an event such as:
• Fire and Rescue
• Safety Car / Course Car
• Medical Responders
• Recovery

This form is to be completed each day of an event.

COVID-19 Questionnaire (Select Options)*

Have you been diagnosed with COVID-19 as confirmed with a positive test for COVID-19(not antibody test)?Have you been in contact with a known COVID-19 positive case in the previous 14 days?Have you been overseas or have been in contact with someone who has been overseas inthe previous 14 days?In the previous 24 hours have you/are you experiencing any symptoms of COVID-19 such as:Fever/chills, cough, shortness of breath/difficulty breathing, muscle pains, headache,sore throat, nausea, vomiting, diarrhoea, runny nose, loss of taste or smell?Have you been in any area or location that has a travel restriction applied due to COVID-19 inthe previous 14 days, except where an exemption is applicable as determined by the relevantGovernment authority?NONE OF THE ABOVE

COVID-19 Questionnaire Score

YOU HAVE ANSWERED YES TO A QUESTION ABOVE

Please make contact via mobile phone to the Event Hotline on 0438 728 910 before proceeding to any area of the event.

A response of YES to any of the above questions will be reviewed by the event organisers (in conjunction with Event Medical personnel) and may result in attendance at the event being denied.

As per the Motorsport Australia Return to Race Strategy testing of a person’s temperature may be conducted at an event.

I understand and agree that my personal data is being processed solely for the purposes of running this Event and may be used for the purposes of COVID-19 infection tracing and will be handled by the organisers in accordance with Motorsport Australia policy.

Please choose the event you are attending*

Your Name*

First NameLast Name

Phone Number*

Mobile number only please

Email*

example@example.com

Motorsport Australia Member / Licence ID Number (if applicable)

Competition Vehicle No. or Official Role*

Signature

Multi-Occupant Vehicle

YOUR DETAILS