Blanchetown Dirt Kart Club Life Membership Application
Please note you must be a financial member of a club before you renew your AIDKA licence.
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Membership Details
Please complete the following information so that we can process your membership application.
Name
First Name
Last Name
Date of Birth
-
Day
-
Month
Year
Residential Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is this the same as your postal address?
Yes
No
Postal Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number (Mobile)
*
Please enter a valid phone number.
Phone Number (Landline)
Please enter a valid phone number.
Email
example@example.com
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Single Membership Licence Details
Please fill out the applicable details for a Single Membership
AIDKA Licence Type
Please Select
Senior
Junior
Pit Crew
Official
AIDKA Licence Number
Please complete your racing/kart details:
Class Competed in normally (eg. Statesman)
Number Competed with (eg. 56)
Kart 1
Kart 2
Kart 3
Kart 4
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Ambulance Cover
You are required to have Ambulance Cover as part of your Licence Conditions. Please complete the following details accurately. Please note - your membership will not be processed without this.
Ambulance Cover Organisation Name
Membership Number
*
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Next Steps
Once you have read and agreed to the Terms and Conditions below and submitted your form your request will be sent to the Licensing Secretary for their processing. Please note, it may take up to 7 days for your membership application to be processed.
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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