North Wales Land Rover Club
Tel: 07768 958906


DRIVER DETAILS

DRIVERS NAME

DRIVER MEMBERSHIP NUMBER (LAND ROVER CLUB IF NOT NWLRC)

EMAIL

ADDRESS

PHONE


EVENT DETAILS

EVENT NAME

EVENT DATE (DD-MM-YYYY)

VEHICLE MODEL/CLASS


OTHER ATTENDEE'S DETAILS

PASSENGER NAME (AGE 14 OR OVER)

PASSENGER MEMBERSHIP NUMBER (LAND ROVER CLUB IF NOT NWLRC)

WILL VEHICLE BE DOUBLE DRIVEN

YesNo

NAME OF SECOND DRIVER (N/A IF NOT DOUBLE DRIVEN)


Details of person to be notified in the event of a serious accident. This should NOT be your passenger.

NAME

ADDRESS

PHONE

RELATIONSHIP WITH COMPETITOR

If the contact for passenger/co-driver is different to the above, please provide details here.


DECLARATION – PLEASE READ BEFORE ACCEPTING

The event will be held under the General Regulations of the Motor Sports Association (incorporating the provisions of the International Sporting Code of the FIA) and the Supplementary Regulations. I have read the general regulations of the Motor Sports Association and, if any, the Supplementary Regulations for this event and agree to be bound by them. I declare that I am physically and mentally fit to take part in the event and I am competent to do so. I acknowledge that I understand the nature and type of the competition and the potential risk inherent with motor sport and agree to accept that risk. Further I understand that all persons having any connection with the promotion and/or organisation and/or conduct of the event are insured against loss or injury caused through their negligence.

BY TICKING THE BOX BELOW, YOU ARE CONFIRMING THAT ALL PARTICIPANTS (AND PARENT OR GUARDIAN FOR ANYONE UNDER 18) AGREE TO THE ABOVE TERMS.


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SUBMIT AND PAY £21.00