Blanchetown Dirt Kart Club Single Membership Application
Please note you must be a financial member of a club before you renew your Dirt Karting of Australia license. At the conclusion of your Membership Application form, you will receive our Bank Details in the 'next steps' section. Please use these Bank Details to make a prompt payment towards your application.
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Membership Details
Please complete the following details in your name as the Parent/Guardian of the child
Name
First Name
Last Name
Date of Birth
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Residential Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Postal Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number (Mobile)
*
Please enter a valid phone number.
Format: 0000-000-000.
Phone Number (Landline)
Please enter a valid phone number.
Format: 0000-000-000.
Email
example@example.com
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Junior Driver Details
Please complete the following details of the Junior requesting membership
Name
First Name
Last Name
Email
example@example.com
Date of Birth
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Postal Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Residential Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: 0000-000-000.
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Junior Membership License Details
Please fill out the applicable details for a Junior Membership
Dirt Karting of Australia Licence Type
Please Select
Junior
Pit Crew
New Member
Dirt Karting of Australia Licence Number
Please complete details on the classes this competitor normally races in:
Rows
Number of Kart (eg. 56)
Class Normally Competed in (ie. Junior Heavy etc.)
Kart Number 1
Kart Number 2
Kart Number 3
Kart Number 4
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Ambulance Cover
You are required to have Ambulance Cover as part of your License Conditions. Please complete the details of your ambulance cover. Please note - your membership will not be processed without this.
Ambulance Cover Organisation Name
*
Ambulance Cover Membership Number
*
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Next Steps
Please make payment via direct deposit to: BSB 065-520 and Account Number 10011139 using your Last Name as the reference. Once payment has been made, please retain your payment confirmation for your records. Processing will commence once the payment has been received and reconciled.
Consent and Terms and Conditions
Please read the following links to ensure you are familiar with the clubs Terms and Conditions and Code of Conduct. Please note that you ticking is your understanding of all that is expected of you. Your submission binds you to complying with these Terms and Conditions and Codes of Conduct and if you are found in contravention of them, your membership may be suspended or cancelled.
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