Blanchetown Dirt Kart Club Family 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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Primary Contact Person Membership Details
Please complete the following as the Primary Contact Person.
Name
First Name
Last Name
Date of Birth
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Address (Residential)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is this address the same as your postal?
Yes
No
Address (Postal)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: 0000-000-000.
Phone Number (Mobile)
Please enter a valid phone number.
Format: 0000-000-000.
Email
example@example.com
Ambulance Cover
You are required to have Ambulance Cover as part of your Licence Conditions. Please upload a current copy of your ambulance cover. Please note - your membership will not be processed without this.
Ambulance Cover Organisation Name
*
Ambulance Cover Membership Number
*
Licence Details
Please fill out the applicable details
Dirt Karting of Australia Licence Type
*
Please Select
Senior
Pit Crew
Official
New Member
Dirt Karting of Australia Licence Number
Complete your kart details:
Rows
Class You Compete In (ie. 125 Heavy)
Your Kart Number (A2. 45)
Your Kart Details
KT Light
KT Medium
KT Heavy
125 Light
125 Medium
125 Heavy
200 Open
Outlaw
Twin
Statesman
100 Open
Your Second Kart (Leave blank if N/A)
KT Light
KT Medium
KT Heavy
125 Light
125 Medium
125 Heavy
200 Open
Outlaw
Twin
Statesman
100 Open
Your Third Kart (Leave blank if N/A)
KT Light
KT Medium
KT Heavy
125 Light
125 Medium
125 Heavy
200 Open
Outlaw
Twin
Statesman
100 Open
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Add another Senior Member?
Do you want to add another senior member to this application? Please note, you can only have a maximum of two.
*
Yes
No
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Second Senior Member
Please complete the details of the second Senior member for this application.
Name
First Name
Last Name
Date of Birth
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Email
example@example.com
Phone Number (Mobile Number)
Please enter a valid phone number.
Format: 0000-000-000.
Phone Number (Landline)
Please enter a valid phone number.
Format: 0000-000-000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Ambulance Cover Organisation Name
*
Cover Membership Number
*
Licence Details
Dirt Karting of Australia Licence Type
*
Please Select
Senior
Pit Crew
Official
New Member
Dirt Karting of Australia Licence Number
Please enter your kart details:
Rows
Your Kart Number (e.g 23 etc.)
Class Raced (eg. 125 Heavy)
First Kart
125 Light
125 Medium
125 Heavy
KT Light
KT Medium
KT Heavy
Statesman
Outlaw
200 Open
100 Open
Twin
Second Kart (leave blank if N/A)
125 Light
125 Medium
125 Heavy
KT Light
KT Medium
KT Heavy
Statesman
Outlaw
200 Open
100 Open
Twin
Third Kart (leave blank if N/A)
125 Light
125 Medium
125 Heavy
KT Light
KT Medium
KT Heavy
Statesman
Outlaw
200 Open
100 Open
Twin
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Junior Members
Please select one option below
Do you want to add one or more juniors to this membership?
*
Yes
No
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Junior Membership (Child No. 1)
Please complete this section for a Junior Membership
Name of Child
First Name
Last Name
Date of Birth
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Parent/Guardian Email Address
example@example.com
Parent Guardian Phone Number
Please enter a valid phone number.
Format: 0000-000-000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Ambulance Cover Organisation Name
*
Ambulance Cover Membership Number
*
Licence Details
Dirt Karting of Australia Licence Type
Please Select
Junior Driver
Pit Crew
New Member
Dirt Karting of Australia Licence Number
Please enter kart details
Rows
Kart Number (ie. 23 etc)
Class Normally Raced (ie. 125 Heavy)
Your First Kart
Rookies
Junior Light
Junior Heavy
Midgets
KT Light
KT Medium
KT Heavy
125 Light
125 Medium
125 Heavy
Your Second Kart (leave blank if N/A)
Rookies
Junior Light
Junior Heavy
Midgets
KT Light
KT Medium
KT Heavy
125 Light
125 Medium
125 Heavy
Your Third Kart (leave blank if N/A)
Rookies
Junior Light
Junior Heavy
Midgets
KT Light
KT Medium
KT Heavy
125 Light
125 Medium
125 Heavy
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Do you want to add another junior to this membership?
Yes
No
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Junior Membership (Child Number 2)
These are the details of the Junior that you are registering for membership
Name
First Name
Last Name
Date of Birth
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Parent/Guardian Email
example@example.com
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.
Ambulance Cover Organisation Name
*
Ambulance Cover Membership Number
*
Licence Details
Dirt Karting of Australia Licence Type
Please Select
Junior
Pit Crew
New Member
Dirt Karting of Australia Licence Number
Please enter your kart details
Rows
Your Kart Number (i.e 23 etc)
Class Normally Competed in (ie. 125 Heavy)
Your Kart Details
Rookies
Midgets
Junior Light
Junior Heavy
125 Light
125 Medium
125 Heavy
KT Light
KT Medium
KT Heavy
Your Second Kart (leave blank if N/A)
Rookies
Midgets
Junior Light
Junior Heavy
125 Light
125 Medium
125 Heavy
KT Light
KT Medium
KT Heavy
Your Third Kart (leave blank if N/A)
Rookies
Midgets
Junior Light
Junior Heavy
125 Light
125 Medium
125 Heavy
KT Light
KT Medium
KT Heavy
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Do you want to add another junior to this membership?
*
Yes
No
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Junior Membership (Child Number 3)
Please complete the details for the third child you wish to add to this membership application
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
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.
Ambulance Cover Organisation Name
*
Ambulance Cover Membership Number
*
Licence Details
Dirt Karting of Australia Licence Type
Please Select
Junior
Pit Crew
New Member
Dirt Karting of Australia Licence Number
Please enter your kart details
Rows
Your Kart Number (i.e 23)
Class normally competed in (ie. 125 Heavy)
Your first kart
Rookies
Midgets
Junior Light
Junior Heavy
KT Light
KT Medium
KT Heavy
125 Light
125 Medium
125 Heavy
Your second kart
Rookies
Midgets
Junior Light
Junior Heavy
KT Light
KT Medium
KT Heavy
125 Light
125 Medium
125 Heavy
Your third kart
Rookies
Midgets
Junior Light
Junior Heavy
KT Light
KT Medium
KT Heavy
125 Light
125 Medium
125 Heavy
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Do you want to add another junior to this membership?
Yes
No
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Junior Membership (Child Number 4)
Please complete this section for the Junior member you are applying for
Name
First Name
Last Name
Date of Birth
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: 0000-000-000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Ambulance Cover Organisation Name and Membership Number
*
Licence Details
Dirt Karting of Australia Licence Type
Please Select
Junior
Pit Crew
New Member
Dirt Karting of Australia Licence Number
Your Kart Details
Rows
Your Kart Number (ie. 23 etc.)
Class Competed In
Your First Kart
Rookies
Midgets
Junior Heavy
Junior Light
125 Light
125 Medium
125 Heavy
KT Light
KT Medium
KT Heavy
Your Second Kart
Rookies
Midgets
Junior Heavy
Junior Light
125 Light
125 Medium
125 Heavy
KT Light
KT Medium
KT Heavy
Your Third Kart
Rookies
Midgets
Junior Heavy
Junior Light
125 Light
125 Medium
125 Heavy
KT Light
KT Medium
KT Heavy
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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
By ticking the box below, you confirm that you and all individuals included in this membership application understand and agree to comply with the Terms and Conditions as well as the Blanchetown Dirt Kart Club's Code of Conduct. Please review the following links to familiarise yourself with these details before proceeding.
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