Official Sprint Entry Form

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PITTSWORTH SPRINTS

FRIDAY 2nd, SATURDAY 3rd SUNDAY 4th SEPTEMBER 2016

Official Sprint Entry Form

Held under the International Sporting Code of the FIA and the National Competition rules of Confederation of Australian Motor Sport

The Meeting is held under the CAMS permit no.______

______

OFFICIAL USE ONLY

Car Number

______

DRIVER Details PLEASE PRINT CLEARLY

Name: ______

E-Mail Address: ______

Postal Address:______Postcode______

Phone Number: ______A/Hours Number ______Mobile______

CAMS Licence No: ______Civil Licence No: ______

Club and Membership Number ______

ENTRANT (CAR OWNER) Details

Name: ______

Address: ______Postcode______

Phone Number: ______A/Hours Number ______Mobile______

DESCRIPTION OF CAR

Make / Model / Year / Body Type
Capacity in CC / Colour / Registered Yes or No / If yes Registration Number

Please tick the appropriate box and continue to where instructed

ROTARY multiply the engine Cubic Capacity (cc) by 1.8(select one of the classes below and continue to where instructed.)

(Mazda rotary engine in standard form are 12a = 1146cc, 13b = 1310cc) (after multiplication select your correct class)

SUPER/TURBO CHARGED (go to section 2, 7 or 8)(all Super/Turbo AWD &4WD vehicles go to section 8)

FOUR & ALL WHEEL DRIVE (all naturally aspiratedAWD &4WD vehicles go to section 6or for Super/Turbocharged go to section 8)

SPORTS CAR2WDNATURALLY ASPIRATED(not a derivative of a family sedan)Go to section 1

SPORTS CAR2WDSUPER/TURBO CHARGED(not a derivative of a family sedan)Go to section 2

(Monaros, Toranas& GT Falcons are NOT sports cars regardless of any modifications done to them)

SPECIAL INTEREST VEHICLES(this class is for vehicles that do not fit into any other class)Go to section 3

(placement into this class will be at the discretion of the event secretary)

NATURALLY ASPIRATED 2WD REGISTERED (carburettor or injection only) Go to section 4

NATURALLY ASPIRATED 2WD UNREGISTERED(carburettor or injection only) Go to section 5

NATURALLY ASPIRATED AWD & 4WD(carburettor or injection only) Go to section 6

SUPER/TURBO CHARGED 2WD(DO NOT multiply your CC unless rotary) Go to section 7

SUPER/TURBO CHARGED 4WD & AWD(DO NOT multiply your CC unless rotary) Go to section 8

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Pittsworth Sprints 2nd / 3rd / 4th September 2016

Sections

1 2WD SPORTS CARS NATURALLY ASPIRATED – Registered and Unregistered (4WD go to section 8)

0cc TO 1600cc 1601cc TO 3000cc 3001cc and over

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2 2WD SPORTS CARS SUPER / TURBO CHARGED – Registered and Unregistered (4WD go to section 8)

0cc TO 1600cc 1601cc TO 3000cc 3001cc and over

______

3 SPECIAL INTEREST VEHICLES(this class is for vehicles that do not fit into any other class)

(placement into this class will be at the discretion of the event secretary)

0cc & Over

______

4 ROAD REGISTERED VEHICLES – TWO WHEEL DRIVE (AWD & 4WD go to section 8)

Naturally Aspirated Vehicles Only (Carburettor & Injection Only)

0cc TO 1300cc 1301cc TO 1600cc 1601cc TO 2000cc 2001cc to 3000cc

3001cc to 4000cc 4001cc to 5000cc 5001cc & over

______

5 UNREGISTERED VEHICLES – TWO WHEEL DRIVE (AWD & 4WD go to section 8)

Naturally Aspirated Vehicles Only (Carburettor & Injection Only)

0cc TO 1300cc 1301cc TO 1600cc 1601cc TO 2000cc 2001cc to 3000cc

3001cc to 4000cc4001cc to 5000cc 5001cc & over

______

6 NATURALLY ASPIRATED – FOUR & ALL WHEEL DRIVE

This class is for Registered and Unregistered vehicles

0cc & Over

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7 SUPERCHARGED AND TURBO CHARGED VEHICLES ONLY TWO WHEEL DRIVE

This class is for Registered and Unregistered vehicles

(Rotary X 1.8 otherwise NO extra multiplication is needed for Supercharged and Turbo Charged)

2 Wheeled Drive Turbo and supercharged (use engine capacity only, multiply only if rotary x 1.8)

0cc TO 2060cc 2061cc & Over

______

8 SUPERCHARGED AND TURBO CHARGED VEHICLES ONLY FOUR & ALL WHEEL DRIVE

This class is for Registered and Unregistered vehicles

(Rotary X 1.8 otherwise NO extra multiplication is needed for Supercharged and Turbo Charged)

4 Wheeled Drive Turbo and supercharged (use engine capacity only, multiply only if rotary x 1.8)

0cc TO 2060cc 2061cc & Over

______

(Please complete and sign disclaimer)

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Competitor Entry Fee

One day $100 or Two days $160

Please note there is NO entry fee for Friday night it is included in your one or two day entry fee.

Entries close 5th August 2016

Please Make Cheques/Money Orders Payable To

“MILLMERRAN AUTO CLUB INC”

RETURN TO: 34 HELENS STREET PITTSWORTH QLD 4356

Direct Deposit

I have paid the entry fee via direct deposit Deposit date ______

Account - Millmerran Auto Club Inc. Sprint account.

Commonwealth Bank Pittsworth BSB 064427

Account number 10048234

Please use your initial and surname as the reference on this deposit.

______

My vehicle will be available for scrutineering FRIDAY SATURDAY

Sunday scrutineering may be arranged by special request.

I intend to compete Friday night

Complete this section if you are entering for one day only. (This does not include Friday night)

I have entered for ONE DAY ONLY

I intend to compete SATURDAY SUNDAY

All competitors are entitled to compete Friday night.

Two free entry arm bands will be supplied with each sprint entry.

I understand to receive free gate entry I MUST BE WEARING

my competitors arm band prior to entering the precinct.

Pit Crew

do not receive a free entry arm band and are expected to pay an entry fee as a spectator.

Please take note of the new disclaimer you will need to fill in all areas relevant to you.

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Pittsworth Sprints 2nd / 3rd / 4th September 2016

THIS RISK WARNING, DISCLAIMER AND INDEMNITY APPLIES

to all competitors, drivers, pit crew and campers who are signing on as part of this entry

Motor Sport Activities are inherently dangerous recreational activities and there is significant risk of injury, disability or death.

If you do not wish to be exposed to such risks, then you should not participate in the Motor Sport Activities.

I acknowledge that:

the risks associated with attending or participating in Motor Sport Activities include but are NOT LIMITED to the risk that I may

suffer harm as a result of:

motor vehicles (or parts of them) colliding with other motor vehicles or persons or property;
others participants acting dangerously or with lack of skills;
high levels of noise exposure;
acts of violence and other harmful acts (whether intentional or inadvertent) committed by persons attending or

participating in the event; and

the failure or unsuitability of facilities (including grand-stands, fences and guard rails) to ensure my safety.

EXCLUSION OF LIABILITY, RELEASE & INDEMNITY

In exchange for being able to attend or participate in the Motor Sport Activities, I agree:

to release CAMS and the Entities to the extent that any or all of them are providing Recreational Services from all liability for:

a) my death;

b) any physical or mental injury (including the aggravation, acceleration or recurrence of such an injury);

c) the contraction, aggravation or acceleration of a disease;

d) the coming into existence, the aggravation, acceleration or recurrence of any other condition, circumstance,

occurrence, activity, form of behaviour, course of conduct or state of affairs:

that is or may be harmful or disadvantageous to me or the community; or
that may result in harm or disadvantage to me or the community,

howsoever arising from my participation in or attendance at the Motor Sport Activities;

to indemnify and hold harmless and keep indemnified the Entities to the maximum extent permitted by law in respect of

any Claim by any person; and

to attend at or participate in the Motor Sport Activities at my own risk.

I understand that:

nothing in this document excludes, restricts or modifies any rights that I may have as a result of significant personal injury that

is caused by the Reckless Conduct of the Entities as the supplier of the Motor Sport Activities / Recreational Services;

nothing in this document prevents the Entities from relying on any laws (including statute and common law) that limit or

preclude their liability;

nothing in this document excludes any term or guarantee which under statute cannot be excluded; however the liability of the

Entities is limited to the minimum liability allowable by law;

nothing in this document precludes me from making a claim under a CAMS insurance policy where I am expressly entitled to

make a claim under that insurance policy; and

CAMS has arranged some limited personal injury insurance coverage which may provide me with some protection for loss,

damage or injury that I may suffer during my participation in the Motor Sport Activities. However, I acknowledge and accept

that the insurance taken out by CAMS may not provide me with full indemnity for loss, damage or injury that I may suffer

during my participation in the Motor Sport Activities, and that I may have to pay the excess if a Claim is made under an

insurance policy on my behalf. I agree that my own insurance arrangements are ultimately my responsibility and I will arrange

any additional coverage at my expense after taking into account CAMS insurance arrangements, this document and my own

circumstances.

DEFINITIONS

a."CAMS" means the Confederation of Australia Motor Sport Ltd.

b.“Claim” means and includes any action, suit, proceeding, claim, demand or cause of action however arising including but not

limited to negligence, BUT does NOT include a claim under a CAMS insurance policy by any person expressly entitled to make a claim under that insurance policy;

c. "Entities" means event and competition organisers/promoters/managers, land and track owners / managers /administrators /lessees, CAMS affiliated clubs, state and territory governments and insured listed in CAMS’ public /product /professional indemnity insurance policies and each of their related bodies corporate (including their related bodies corporate) and each of their organs and agencies, officers/president/directors/executives, employees, servants, agents, partners, providers, members, competitors, drivers, co-drivers, navigators, officials, crew members, pit crew, delegates, licence holders, representatives, commissions, committees, advisers, trustees, councils, panels, shareholders, volunteers, officials,

appointees, delegated bodies and sponsors.

d. "Motor Sport Activities" means any motor sport activities or Recreational Services which are permitted or approved which CAMS regulates or administers by CAMS or otherwise under the responsibility / control of CAMS;

e. "Reckless Conduct" means conduct where the supplier of the recreational services is aware, or should reasonably have been

aware, of a significant risk that the conduct could result in personal injury to another person and engages in the conduct despite the risk and without adequate justification;

f. "Recreational Services" means (unless otherwise defined in this document) services that consist of participation in:

a) a sporting activity; or

b) a similar leisure time pursuit or any other activity that:

(i) involves a significant degree of physical exertion or physical risk; and

(ii) is undertaken for the purposes of recreation, enjoyment or leisure.

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Pittsworth Sprints 2nd / 3rd / 4th September 2016

Entry Declaration Signatures

Competitor .………………………………………………

Driver..………………………………………………….…

DECLARATION

I accept the conditions of, and acknowledge the risks arising from, attending or participating in the Motor Sport Activities

being provided by CAMS and the Entities. I agree to comply with all policies, rules, regulations and directions of CAMS and

the Entities in relation to this event.

I have read, understood, acknowledge and agree to the above including the exclusion of statutory guarantees, warning,

assumption of risk, release and indemnity:

Competitor Sign………………………………………………………………………Date ………………………………………………….

Driver Sign……………………………………………………………………………. Date ………………………………………………….

Witness Sign...... Date ………………………………………………….

Name of Witness …………………………………………………………………….

Address of witness …….……………………………………………………………………..……………………………………………………

For persons under the age of 18 years the following parent/guardian consent must be completed.

PARENT/GUARDIAN CONSENT – PERSONS UNDER 18 YEARS OLD

I …………………………………… of [Address] ………………………………………………… ……………………………………

am the parent/guardian* of the above-named ("the minor") who is under 18 years old. I have read this document and

understand its contents, including the exclusion of statutory guarantees, warning, assumption of risk, release and indemnity,

and have explained the contents to the minor. I consent to the minor attending/participating in* the event at his/her own risk.

* Delete whichever does not apply

Name of Person/s (minor)……………………………………………………………… Minor’s Date of Birth ………………………………

Minor’s Signature …………………………………………..

Parent/Guardian*Signature...………………………………………………………Date ………………………………………………..

Witness Signature: ...... Date ….…………………………………………….

Name of Witness …………………………………………………………………….

Address of Witness …….……………………………………………………………………..……………………………………………………

PLEASE RETURN THIS PAGE WITH YOUR COMPLETED ENTRY FORM

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Pittsworth Sprints 2nd / 3rd / 4th September 2016

Pit Crew Declaration Signatures

Competitor: .………………………………………………

Driver: ..………………………………………………….…

DECLARATION

I accept the conditions of, and acknowledge the risks arising from, attending or participating in the Motor Sport Activities

being provided by CAMS and the Entities. I agree to comply with all policies, rules, regulations and directions of CAMS and

the Entities in relation to this event.

I have read, understood, acknowledge and agree to the above including the exclusion of statutory guarantees, warning,

assumption of risk, release and indemnity:

PIT CREW MEMBER 1 (Please Sign)
NAME ………………………………………………………….…..…..…...
SIGNATURE ………………………………………………………………. / PIT CREW MEMBER 2 (Please Sign)
NAME …………………………………………………………..….…….….
SIGNATURE ……………………………………………………………….
PIT CREW MEMBER 3 (Please Sign)
NAME ……………………………………………………………………….
SIGNATURE …………………………………………………………..…[. / PIT CREW MEMBER 4 (Please Sign)
NAME …………………………………………………………………….…
SIGNATURE ……………………………………………………………….
PIT CREW MEMBER 5 (Please Sign)
NAME ……………………………………………………………………….
SIGNATURE ………………………………………………………………. / PIT CREW MEMBER 6 (Please Sign)
NAME ……………………………………………………………………….
SIGNATURE ……………………………………………………………….
PIT CREW MEMBER 7 (Please Sign)
NAME ……………………………………………………………………….
SIGNATURE ………………………………………………………………. / PIT CREW MEMBER 8 (Please Sign)
NAME ……………………………………………………………………….
SIGNATURE ……………………………………………………………….
PARENT/GUARDIAN CONSENT – PERSONS UNDER 18 YEARS OLD
I am the parent/guardian* of the above-named ("the minor") who is under 18 years old. I have read this document and
understand its contents, including the exclusion of statutory guarantees, warning, assumption of risk, release and indemnity,
and have explained the contents to the minor. I consent to the minor attending/participating in* the event at his/her own risk.
PARENT/GUARDIAN* (Delete which does not apply)
NAME: ......
ADDRESS: ......
...... Postcode: ......
Signature …………………………………………………………………...
Crew Member……………………………………………………………… / PARENT/GUARDIAN* (Delete which does not apply)
NAME: ......
ADDRESS: ......
...... Postcode: ......
Signature ……………………………………………………………………
Crew Member……………………………………………………………….
Witness Signature: ………………………………………………………………………………………………………………………………………………
Name of Witness …………………………………………………………………………………………………………………………………….
Address of Witness: ……………………………………………………………………………………………………….………………………..

PLEASE RETURN THIS PAGE WITH YOUR COMPLETED ENTRY FORM

Page 6 of 7

Pittsworth Sprints 2nd / 3rd / 4th September 2016

Please note the area used for camping at Pittsworth is Crown Land and therefore the Pittsworth Sprint Committee cannot grant or refuse permission to camp there. If you decide to camp at the Pittsworth Sprint please fill in the disclaimer below.

Camping Declaration Signatures

Competitor: .………………………………………………

Driver: ..………………………………………………….…

DECLARATION

I accept the conditions of, and acknowledge the risks arising from, attending or participating in the Motor Sport Activities

being provided by CAMS and the Entities. I agree to comply with all policies, rules, regulations and directions of CAMS and

the Entities in relation to this event.

I have read, understood, acknowledge and agree to the above including the exclusion of statutory guarantees, warning,

assumption of risk, release and indemnity:

Name: ………………………………………………………………..….Signature: ……………………………………………….

Name: ………………………………………………..………………….Signature: ……………………………………………….

Name: ………………………………………………………………..….Signature: ……………………………………………….

Name: ………………………………………………..………………….Signature: ……………………………………………….

Name: ………………………………………………………………..….Signature: ……………………………………………….

PARENT/GUARDIAN CONSENT – PERSONS UNDER 18 YEARS OLD
I am the parent/guardian* of the above-named ("the minor") who is under 18 years old. I have read this document and
understand its contents, including the exclusion of statutory guarantees, warning, assumption of risk, release and indemnity,
and have explained the contents to the minor. I consent to the minor attending/participating in* the event at his/her own risk.
PARENT/GUARDIAN* (Delete which does not apply)
NAME: ......
ADDRESS: ......
...... Postcode: ......
Signature …………………………………………………………………...
Crew Member……………………………………………………………… / PARENT/GUARDIAN* (Delete which does not apply)
NAME: ......
ADDRESS: ......
...... Postcode: ......
Signature ……………………………………………………………………
Crew Member……………………………………………………………….
Witness Signature: ……………………………………………………………………………………………………………………………………………
Name of Witness …………………………………………………………………………………………………………………………………….
Address of Witness: ……………………………………………………………………………………………………….………………………..

PLEASE RETURN THIS PAGE WITH YOUR COMPLETED ENTRY FORM

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