NEIL ROBINSON MEMORIAL RACES.

Promoted by the MID ANTRIM 150 CLUB Ltd.

Event Sponsor: MJF BUILDING SERVICES.

ENTRY FORM

Bishopscourt Race Circuit on Saturday & Sunday 8/9 July 2017

MCUI (UC) Permit No. 036/17

NAME: / PASSENGER
ADDRESS:
PostCode: / ADDRESS
PostCode
TELEPHONENo: / TELEPHONENo:
E-MAIL / E-MAIL
Comp. Lic.No: / A / B / BN / Comp. Lic.No: / A / B / BN
UNDER 18D.O.B.
ENTRANT IF NOTRIDER / ENTRANT LICENCENo:
NEXT OF KIN: (Name & ContactNo) / Club Member:
Make ofMachine / Capacity / Event/Rid.No. / Sat/Sun/Both / TransponderNo
MOTORSPORTSCANBEDANGEROUSANDMAYINVOLVEINJURYORDEATH
Youmustreadandagreetothefollowingdeclarationandparagraphsbelowwhicharedesignedtocreatealegallybindingrelationship in return for your being allowed to enter andcompete
1.Iconfirmthattheinformationinthisentryformandtheinformationandmyacceptanceofthetermsofmycompetitionlicencearecorrect.
2.IconfirmthatIunderstandthenatureofthecompetitionIamentering andIamcompetenttotakepart.
3.IconfirmthatanyvehiclethatIusewillcomplywiththeregulationsandwillbesafeandfit foruseinthecompetition.
4.Iwillsatisfymyself(bysightinglaporotherwise)beforetakingpartthatthevenueandtrackisacceptabletomewithregardtoitsfeaturesandphysicallayout(unless prohibited to doso).
5.IwillNOTtakepartifIhaveanydoubtsaboutmyabilityorsafetyofthevenue.
6.IacceptthatcompetitioninmotorcyclesportmayinvolveinjuryordeathandIagreetotakepartatmyownrisk.
7.BeforetakingpartintheeventIwillreadandbeboundbyandcomplywithanyregulationsandfinalinstructionsissuedbytheorganiser,circuitownersandthegoverningbodies.
8.IwillnotparticipatewhilstundertheinfluenceofalcoholorintoxicatingdrugsandthatifIamtakinganyprescribedmedicationIwillinformtheeventpromoter and seek approval to participate before takingpart.
9.Ifundertheageof18,myparent/guardianhasreadtheaboveandsignedthedeclarationandagreementbelow.
Signed: / Date:
MOTORSPORTS CAN BE DANGEROUS AND MAY INVOLVE INJURY ORDEATHPARENTS/GUARDIAN DECLARATION ANDAGREEMENT
Toallowtheapplicanttoenterthecompetitionyoumustagreetothematterssetoutbelowwhicharedesignedtocreatelegalobligations on you. Sign below only if youagree
a)I(Print Name) am the Parent/Legal Guardianof
b)Ihavereadtheentryformanddeclarationcompletedthebytheapplicantandconfirmtheanswersaretrue.
c)Iconfirmthathe/sheiscompetenttotakepartintheeventandthatanyvehiclewhichhe/shewilluseissafeandfitforthecompetition.
d)Iwill,beforeallowinghim/hertotakepart,satisfymyselfthatthecourseandfacilitiesaresafeandwillinspectsame.
e)IalsoherebyAGREEthatif theapplicantshouldsustainanyinjuryfromanycausewhilsttakingpartintheeventandasaresultbringaclaim forcompensation againstyouortheorganisersorofficialsorsponsorsorentrants orowners ofthevenue,IWILLINDEMNIFYANDPAYBACKTOYOUanysumwhichyoumayberequired to pay as a result of suchclaim.
Signed: / Date:
Address (if different fromapplicant)
ENTRY FEE FOR TWO DAYS: £140 (€160) per class. 2nd ENTRY £100 (€120) if fully paid up and received by 24/6/17:
ENTRY FEE FOR ONE DAY: £80 (€95) ------SIDECARS: £160(€185) Per outfit:
Entries received after this date or not fully paid will cost an additional £20 (€25) per class.
Event4&4a only: Under16 years of Age £50 (€60) for two days: £30 (€35) for one day.
PAYMENTMAYBEMADEBYSTERLINGCHEQUE,POSTALORDER,CASHOREUROCHEQUE/€ cash
No € postal orders will be accepted
No post dated cheques accepted, and no cheques will be accepted on the day.
CHEQUES /POSTAL ORDERS TO BE MADE PAYABLE TO: MID ANTRIM 150 CLUB Ltd.
To be received by closing date of SATURDAY 24TH June 2017.
Entries received after this date may not be accepted for theEvent.
PASSES WILL NOT BE SENT AN ENTRY LIST WILL BE CHECKED AT GATE.
Entriesto:JACK AGNEW, 11 KNOCKAN ROAD, BROUGHSHANE, BALLYMENA, Co. ANTRIM, BT42 4JY. 07411485588
HealthSafetyatWork(NI)order1978:Thefollowinginformationisrequiredinorderthattheorganisercanmakeprovisionforsecuringthehealth,safetyandwelfareforpersonsatworkatthissportingeventandforprotectingothersagainstriskstohealthorsafetyinconnectionwiththeactivitiesofpersonsatworkas required under The Health and Safety W(NI) Order1978.
Selectoneofthefollowingemploymentcategorieswhichmayapplytoyouinrelationtoyourparticipationinthisevent
Employee – Someone working under a contract of employment. i.e. subject to the authority and instruction of theemployer.
Non- Employed–Apersonengaginginsportasapast-timeforpleasureratherthan financialbenefitorprofessionalreasons.
Self-Employed–Personwhoworksforgainorrewardotherwisethenundercontractofemployment,whetherornothehim-selfemploysothers.