SCCoN 12 Car

Please ensure you have a valid Motorsport UK RS Clubman licence and club membership before entering this event

Car No

Event Name

Permit No:

Event Date:

Driver*

Address*

Tel Number*

E-mail*

Next of Kin & phone no*

Confirmation of RS Clubman or Inter-club Motorsport UK Licence

Driver MSUK Licence No.*

Driver Club and Membership No*

Navigator*

Nav Address*

Nav Tel Number*

Nav E-mail*

Nav Next of Kin & phone no*

Confirmation of RS Clubman or Inter-club Motorsport UK Licence

Nav MSUK Licence No.*

Navigator Club and membership No:*

Car Make*

Car Model*

Reg*

CC*

Colour*

Class*

BEGINNERNOVICEINTERMEDIATEEXPERT

Insurance Required*

NoYes

INSURANCE

Vehicles must have a valid motor insurance policy which provides as a minimum,Third Party Liability cover that complies with the Road Traffic Act. This can be either, by extending an existing motor policy to cover the event, or, by purchasing additional cover, providing under the Event Road Section Scheme as an adjunct to an existing motor policy. If a competitor has an extension to their existing policy,they will be required to sign a declaration that the cover complies with the requirements of the Road Traffic Act. Any responsibility for a fraudulent or misleading declaration about existing cover lies with the competitor.

If a competitor wishes to purchase additional Road Section cover via the organisers,then they can do so prior to the event providing they comply with the following:

• is aged 19 years or over
• has held a full driving licence for a minimum of 6 months
• has no more than 6 points on their licence
• has had no more than 1 fault claim in the last 3 years is named on a valid motor insurance policy for the vehicle they are driving
• do not have the Third-Party Extension cover on their existing motor policy
• the vehicle has a valid MOT and taxed for the road, unless exempt from doing so

Anyone aged less than19 years old will also be accepted at the same price should their co-driver be a more senior member of their family or over 25. Any competitor who falls outside of these parameters may be offered cover at equivalent terms or an agreed price, if approval from the Appointed Insurance Broker has been obtained by the event organisers, prior to the event. Approval can be sought by sending an email to teresa.knight@reis.co.uk and provide the Drivers’ name and date of birth, the date they past their driving test and details of any motoring claims and/or convictions.

Additional cover provided by this scheme is only effective whilst the vehicle is actively competing in the event and remains under the control or direction of the event organiser(s). Cover will cease immediately if you are precluded, excluded or retire from the event.

The Event Road Section scheme is provided by Reis Motorsport Insurance and underwritten by Slipstream Underwriting a trading style of First Underwriting Limited.

The basic rate per driver for the Insured event, before any loadings will be £20.00 including insurance premium tax at 12%, and £1.50 policy fee.

1. I have been given an opportunity to read the General Regulations of the Motorsport UK 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 and competent to take part in the event. I understand that motorsport is 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. 2 . 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. 3 . The use of the vehicle hereby entered is covered by insurance as required by the law which is valid for such part of this event as shall take place on roads as defined by the law. 4 . 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 the 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. 5 . Any application form for a Licence which was signed by a person under th e age of 18 years was countersigned by that person’s parent/legal guardian/guarantor, whose full names and addresses have bee n given. 6 . 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 MOTORSPORT UK. As the Parent/Guardian/Guarantor I confirm that I have acquainted myself with the MOTORSPORT UK 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 maximum set out in Part 3, Appendix 1. Note: Where the Parent/Guardian/Guarantor is not present there must be a representative who must produce a written and signed authorisation to so act from the Parent/Guardian/Guarantor as appropriate. 7 . I hereby agree to abide by the MOTORSPORT UK Child Protection Policy and Guidelines and the National Sporting Code of Conduct. 8. 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. (H10.1.6) 9 . I have read and fully understood the Procedure for Control of Drugs and Alcohol as contained in the MOTORSPORT UK 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 MOTORSPORT UK (as amended). 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 (Art 5.6.2) I hereby confirm that I give such consent for the minor concerned to be so tested. Indemnity : In consideration of the acceptance of this entry I agree that neither any one of or any combination of the MOTORSPORT UK and its associated clubs, the organisers, the land 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 this event. 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 agree to SCCON & WSMC retaining my details and contacting me regarding other motorsport events that the club is involved with. Neither SCCON or WSMC will not under any circumstances pass on your details to any other person or organisation.

Agreement to Regs*

I AgreeI do not agree.

Entry Fee £25.00 Insurance £22.00

An entry is not valid until payment has been received

You will receive emails before the event asking you to sign on, both of which must be completed. Once you have signed on please ignore any duplicate emails asking you to sign on again.

Please ensure all details are complete and correct with no TBC's, don't knows, or as before's.