Untimed National Hillclimb Practice day

UNTIMED NATIONAL HILLCLIMB PRACTICE DAY

Location: Shell V-Power Motorsports Park, Eastern Circuit - 543 Dukes Hwy Tailem Bend SA 5260
Driver Information
Driver's Name*

First Surname
Address

Street Address

Street Address Line 2

CityState

Post Code
Date of Birth*

DayMonthYear
Date
Phone Number
Please enter a valid phone number.
Email
example@example.com
Emergency Contact / Medical Details
Emergency Contact Person*

Full NameContact Number
Relationship to Driver*
Drivers Medical Conditions
Does the competitor have any allergies, chronic illness, or medical conditions? If yes , please describe.

Car Details
Car type / Model*
Electric vehicle

Must supply a saftey plan relevent to their vehicle,this must be printed and brought with you to the event. A Motorsport Australia EV log book must be applied and granted prior to the event and have this avaliable at documentation.
Log Book Number
Electric Vehicles. I have the following.

Motorpsort EV Log BookSafety plan relevant to my vehicle
Upload you Motorsport Australia Licience and Club Membership
Motorsport Australia Licence*

upload current MA licence - This must show licence number and expiry date
Cancelof
Club Membership card*

upload current Club Membership
Cancelof
Motorsport Australia Licence number and expiry date*
Club Membership expiry date*
Duel Entered Vehicle

All drivers must complete separate entry forms
Additional drivers sharing the same vehicle

Entry Fee and Payment details - Per Driver
Account Name : Hillclimb SA Incorporated,

BSB: 633 000, Account Number: 198 050 031

Please make sure you use your surname as reference for payment so we can allocate funds correctly. e.g "SURNAME AHCC"
Registration Fee*
prevnext( X )
UNTIMED NATIONAL PRACTICE DAY 1This is an untimed practice day for the Nation Hillclimb Championship in October 2025. All Payments must be made with the correct reference for payment of "SURNAME PAHC"
$250.00AUD

Total

$0.00AUD
ENTRY WILL NOT BE FINALISED TILL PAYMENT IS RECEIVED

Parent / Guardian Details

(all juniors aged 14-17 must have a parent of guardian signature and they must be present at all times at the event)
Parent/ Guardian full Name

NameContact Number
Parent/ Guardian's Signature

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Photographic Release & Signature

I hereby acknowledge that the information given above is accurate and I give permission to the organisers to use of my photographs that are taken by staff in order to use for social media.
Driver's Signature*

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UNTIMED NATIONAL HILLCLIMB PRACTICE DAY