Victorian Superkart Club Try Drive Event Registration
Please note: payment is due on the day PRIOR to going out for a Try Drive. Ensure you speak with the Race Secretary to make payment and sign in on the day.
Which event is this for?
Rd 4 Broadford - 18 May 2019
Rd 6 Broadford - 13 July 2019
Full Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State
Post Code
E-mail
Phone Number
-
Area Code
Phone Number
Have you ever been diagnosed as having and / or had treatment for the following:
A psychiatric or psychological illness?
Yes
No
Persistent or severe headache, head injury, epilepsy, seizure or loss of consciousness?
Yes
No
Heart or lung disease, including infection, blood vessel disease, hypertension, coronary bypass, angioplasty or other surgical procedures?
Yes
No
Cancer, diabetes, kidney, liver, thyroid, gastrointestinal, blood pressure disorders, including any associated surgical procedures?
Yes
No
Significant illness, injury or surgery not already noted?
Yes
No
Have you taken any medications, including self medications or alternative therapies orally or by injection in the last five years or currently?
Yes
No
Is your hearing impaired in any way?
Yes
No
Do you suffer from any disorder including tinnitus?
Yes
No
Is your eyesight normal in both eyes for distance vision?
Yes
No
If no, is your eyesight correctable?
Yes
No
Do you wear spectacles or contact lens?
Yes
No
When did you have your last medical examination?
-
Day
-
Month
Year
Date
If you answered YES to any of the medical question above, please provide full details including medications
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