Rallysprint Entry Form

Rallysprint Entry Form
Event: Coopernook Sprint-Rally
Date:14/11/2026
Event Organiser: Hastings Sporting Car Club

AMSAG Event Nr: 2026-0011

AASA Permit Nr: AASA141126-104005
Driver Information
Driver's Name

First NameLast Name
Driver Date of Birth

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Driver Phone Number
Phone Number
Driver Email
example@example.com
Driver Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Competition License Nr
License nr
Competition License Expiry

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
MA or AASA License ?
AMSAG Member Nr
Member number
Civil Drivers License Nr
License Nr
Civil License Expiry

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Male/Female
Driver Emergency Contact

First NameLast Name
Driver Emergency Phone Nr
Driver Relationship to Emergency Contact
I.e wife, , husband, partner
Navigator Information
Navigator’s Name

First NameLast Name
Navigator Date of Birth

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Navigator Phone Number
Phone Number
Navigator Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Nav Competition License Nr
License nr
Competition License Expiry

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
MA or AASA License ?
AMSAG Member Number
Member Number
Civil Drivers License Nr
License Nr
Civil License Expiry

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Male/Female
Navigator Emergency Contact

First NameLast Name
Navigator Emergency Phone Nr
Phone Number
Navigator Relationship to Emergency Contact
I.e wife, , husband, partner
Car Details
Make
Model
Year
Year
License Plate Number
Car Colour
Colour
Registration State
Logbook Nr
Logbook nr
Engine Capacity (cc)
Capacity in CC
Turbo/Supercharged ?
Categories and Classes

AMSAG Classic Category
- Class A 0 to 1800cc
- Class B 1801 to 2200cc
- Class C 2201 to 3000cc
- Class D 3001cc and over plus Rotaries
AMSAG Open Category
- 2WD
- 4WD
Class Entered
Entry Fee
Entry Fee - $495

Payment Electronic Funds Transfer Only

Please add drivers surname as a reference.

Regional Australia Bank

BSB: 932000

Account: 500203883

Account Name: Hastings Sporting Car Club inc
Have you paid ?
Date Paid

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Sign & Submit

By signing this entry form you agree to all information supplied in the Supplementary Regulations and any further advice provided by the event organisers.
It is a condition of entry that the Driver and Navigator intending on competing

in the event both agree to the AASA Indemnity Waiver, a copy of which can be found here:

AASA Release and Waiver of Indemnity

Please select below if you have entered details for both Driver and Navigator and both parties agree to the Release and Waiver of Indemnity.
We agree to the Release and Waiver of Indemnity
If you do not have Navigator details for your entry at the time of your entry submission, an agreement will need to be made prior to the event once a Navigator has been added to your Entry. You will need to complete an Event Entry Amendment Form which can be found on the Events page.

For any competitors aged under 18 years at the time of the event, a waiver will need to be signed by the Parent or Guardian of the competitor.

Parental Consent Form

Please print out the Release and Indemnity Waiver from the above link, have the form signed by the appropriate Parent or Guardian and forward to the Event Secretary prior to the event.
Driver's Signature
Navigator’s Signature
Date Signed

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Should be Empty:

Rallysprint Entry Form

Driver Information

Navigator Information

Car Details

Entry Fee

Sign & Submit