Wellington Motocross Champs 2019

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Team name   First name   Last name   Email address   Date of birth DD 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31    MM 01 02 03 04 05 06 07 08 09 10 11 12       YYYY 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920    Gender -- Male Female   Phone #   Address   Emergency contact name   Emergency phone #   Classes Choose one Junior Mini Pit Bikes Senior   Class Choose one 125cc 12-16 years 250cc 14-16 years 85cc 12-16 years 85cc 8-11 years Choose one 50cc Intro 4-8 yrs trail 50cc Intro MX 4-7 years 50cc MX 6-8 years 65cc MX 7-8 years 65cc MX 9-11 years Trail 7-11 years Choose one Pit Bike Open Choose one National 250cc (MX2) National 450cc (MX1) Support Veterans Womens   Event entry fee increases after May 4, 2019 Event entry fee TBD

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Please review the waiver provided by the event organizer and click the check box below to accept it. Print waiver To Gold Coast Motorcycle Club I have read the Suppplementary Regulations for this Competition and agree to be bound by them. I am aware that the sport of Motorcycle Competition might a) cause me injury; serious or otherwise b) damage my property or c) make me cry I wish to take part in the Wellington Motocross Championship competition despite the above risks Neither I, nor anyone associated or connected with me will make any claim against you or your officers, employees or agents in respect of: a) any injury suffered by me; or b) any damage to any of my property regardless of how the injury or damage occurs. I will indemnify you against all claims, damages or losses (including costs) which you incur as the direct or indirect result of any injury to me or damage to my property. I am physically fit and there is no health or other reason why I should not participate in the sport of motorcycle competition. I am aware that this disclaimer will not affect any legal obligations you have to me which you cannot contract out of under NZ Law. I agree that in this disclaimer “my property” includes any property owned by me or in my possession or under my control. I agree that this disclaimer will be binding on my family, my heirs, my legal assigns and my administrators and executors. I accept that stripping and re-assembly for Technical Checks are at my cost. I consent to the details contained in this form being held by the Gold Coast Motocross Club for the purpose of the promotion and the benefit of the race meeting concerned and motorcycling in general. I acknowledge my right to access and correction of this information. This consent is given in accordance with the Privacy Act 1993. Gold Coast Motocross Club supports the FIM/IOC Charter on drugs in sport. Gold Coast Motocross Club uses the services of the NZ Drug Sports Agency (NZSDA) to professionally carry out the testing. I acknowledge by signing this form I may be subjected to a drug/alcohol test at any time. I agree to such testing. I further agree that my name can be published by Gold Coast Motocross Club as having taken part in a drug/alcohol test together with the results of that testing. I accept the terms of the waiver Name of parent or guardian who approves this activity Please enter your name here