Entry Form

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ENTRY FORM

2020 Safari Darling Rally

Please complete this form with all relevant details correctly formatted to ensure your entry is accepted.
Supp Regs can be downloaded from http://rallywa.com/event/safari-rally/
Please select which competition you are entering (Note: WA 2WD will also be automatically entered in WARC)

DRIVER

DRIVER DETAILS

Do you have a current First Aid Certificate (or higher medical qualification) or have you completed the RallyWA RIMS Training?
Do you suffer from any Allergies or are you taking any medications that may affect treatment should it be required in an Emergency (e.g. 'blood thinners') please indicate below.

At documentation, please provide the Event Secretary with details of Medications contained in a sealed Envelope (labelled with your Name, CAMS Licence #, Date of Birth and Car #) to be passed on to the Chief Medical Officer

You are considered a RallyWA Rookie if, as a Driver, you have you started in no more than 2 rallies prior to the commencement of this current season.
Emergency Contact
Please provide the Name and Mobile number for your next of kin in the event of an emergency.

CO-DRIVER

CO-DRIVER DETAILS

Do you have a current First Aid Certificate (or higher medical qualification) or have you completed the RallyWA RIMS Training?
If you suffer from any Allergies or are taking any medications that may affect treatment should it be required in an Emergency (e.g. 'blood thinners') please indicate below.

**If YES, at documentation you must provide the Event Secretary with a sealed Envelope clearly labelled with your Name, CAMS Licence, Date of Birth and Car # which will be given directly to the Chief Medical Officer**

At documentation, please provide the Event Secretary with details of Medications contained in a sealed Envelope (labelled with your Name, CAMS Licence #, Date of Birth and Car #) to be passed on to the Chief Medical Officer

You are considered a RallyWA Rookie if, as a Co-Driver, you have you started in no more than 2 rallies prior to the commencement of this current season.
Emergency Contact
Please provide the Name and Mobile number for your next of kin in the event of an emergency.

COMPETITOR/ENTRANT

COMPETITOR/ENTRANT

Please provide details of the Competitor, (previously referred to as "Entrant"), typically the Vehicle Owner. Refer NCR 43, 43A. The vehicle owner is the Person or Entity (in the case of a business) listed in the Motorsport Australia Logbook/Registration Papers.
Who is the REGISTERED Owner of the Vehicle?
(if applicable)

If the Driver is not the registered owner then a Letter of Authority is required from the Registered Owner allowing the Driver to compete using the vehicle and must be presented at Documentation.

A fillable PDF template can be downloaded from the Event Documentation section on www.rallywa.com

VEHICLE

SPONSOR & CAR DETAILS

Are ALL your vehicle details and Sponsor the same as the last Rally you competed in THIS year?
If applicable, please list your Sponsor that will appear on the Entry List.


Rally Permits:
RallyWA has been asked to remind ALL competitors that when applying for an Over 48 hour Permit for their unlicensed Rally Car that you must allow 14 days for processing. In the past the Department have had the resources to process the applications quite quickly, however due to current workloads this is no longer the case and 14 days notice will be required. Also, note that the normal 48 Hour Permit that you can apply for online is NOT suitable for use during a rally and can not be used. The correct form can be downloaded from the www.rallywa.com
Engine Capacity:
Remember to include the capacity equivalence factors of 1.7 if Turbo/Supercharged, and 1.8 if a Rotary.

RECCE / SERVICE VEHICLE(S)

RECCE & SERVICE CAR DETAILS

Please provide details of the car you will be using during reconnaissance

Please provide details of the car your service vehicle.

Please provide details of your car trailer.

SERVICE CREW

SERVICE CREW & TEAM MANAGER

Please provide details of your Team Manager or the main contact should we be unable to contact the Driver/Co-Driver during the event eg to organise vehicle recovery etc.
SERVICE CREW
Up to 8 crew including the Service Crew Chief are included in your entry. Additional crew can be registered at extra cost.   Note: All Service Crew must sign the CAMS Disclaimer prior to the event.   Please download a Service Crew form here (fillable PDF). PLEASE PRESENT THE COMPLETED SERVICE CREW FORM AT DOCUMENTATION

PAYMENT

PAYMENT DETAILS

Reminder: Your Entry Fee must be received in full prior to close of entries in order for your entry to be accepted.
Please select your preferred payment method.

BSB: 066125
Account #: 10194375
Ref: Drivers Surname and WARC or Clubman

Please contact safari@rallywa.com to arrange a Credit Card Payment.

Please note a 1.5% Admin Fee applies to all Credit Card payments.

Please advise the business name should you require a Tax Invoice to be supplied. Leave blank if an invoice is not required.

MOTORSPORT AUSTRALIA DISCLAIMER

 

RISK WARNING AND DISCLAIMER

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 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 and Indemnity

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

  • to release Motorsport Australia and the Entities to the extent that any or all of them are providing Recreational Services from all liability for:
    • my death;
    • any physical or mental injury (including the aggravation, acceleration or recurrence of such an injury);
    • the contraction, aggravation or acceleration of a disease;
    • 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 Motorsport Australia and the Entities to the maximum extent permitted by law in respect of any Claim by any person;
  • to be bound to the rules, regulations and policies of the Entities; 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 Motorsport Australia and the Entities as the supplier of Motor Sport Activities and 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 Motorsport Australia insurance policy where I am expressly entitled to make a claim under that insurance policy; and
  • Motorsport Australia 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 Motorsport Australia 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 Motorsport Australia insurance arrangements, this document and my own circumstances.

Definitions:

a. “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 Motorsport Australia insurance policy by any person expressly entitled to make a claim under that insurance policy;
b. “Entities” means event and competition organisers/promoters/managers, land and track owners/managers/administrators/lessees, Motorsport Australia affiliated clubs, state and territory governments and insureds listed in Motorsport Australia’s 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;
c. “Motorsport Activities” means any motorsport activities or Recreational Services which are permitted or approved which Motorsport Australia regulates or administers or otherwise are under the responsibility / control of Motorsport Australia;
d. “Motorsport Australia” means the Confederation of Australia Motor Sport Ltd. trading as Motorsport Australia;
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.

ANY APPLICANT MAKING A FALSE DECLARATION IS LIABLE TO REFUSAL AND CANCELLATION OF LICENCE AND/OR INSURANCE COVER. I accept the conditions of, and acknowledge the risks arising from, attending or participating in Motor Sport Activities being provided by Motorsport Australia and the Entities. I agree to be bound by the rules, regulations and policies of Motorsport Australia at all times as a condition of continuing to hold a licence. The information I have entered into this form is true and correct and I will advise Motorsport Australia immediately if any of the information I have given is no longer true and correct. I have read, understood, acknowledge and agree to the above including the exclusion of statutory guarantees, warning, assumption of risk, release and indemnity

SUBMIT ENTRY

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List of Entries to date:

COMPETITIONFirst NameSurnameRookieSponsorMakeModel
Clubman CupTomvan KannNoSupply SolutionsDatsun200B
Clubman CupDermyO’Donovan YesHamersley Electrical ContractingMitsubishi Mirage
Clubman CupGlennCawoodYesShedforce Mitsubishi Lancer
Clubman CupMichaelConnorYes HyundaiExcel