NZ JUNIOR MX CHAMPIONSHIP
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Mosgiel District Motorcycle Club
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INDIVIDUAL ENTRY FORM FOR THE 6 HOUR CHALLENGE
Entries close - 6th March 2017
for full event information
Entries limited to first 100 teams & 50 individuals. Competitors may only enter one class.
Please ensure all Compulsory fields are completed and then
at bottom of this page
Any queries regarding this event, please refer to supplementary regulations for contact details of event organisers
CLASSES (Please select from drop down list below)
Note: 6 Hour Solo Ladies are combined with the Ladies/Mixed Sex Team Class
Indicates required field
Class entered (Please select from drop down list)
3 Hour Ironman (1 bike/1 rider)
6 Hour Ironman (1 bike/1 rider)
Ladies/Mixed Sex/Solo 6 Hour Ladies)
Ladies/Mixed Sex - To be eligible for this class at least one rider must be female (17 years & above)
Machine & Capacity
Date of Birth DD/MM/YY
MNZ Licence # or OE if One Event Lic required
Individual Entry Fee - $50
Complimentary One Event Licences supplied by MNZ
Intended Payment Method
Cheque Being Sent
Total Payment $
Senior Competitors only (17years and above) for this event.
to see the terms and conditions (Supplementary Regulations)
I have read and accepted Disclaimer of Liability below.
I confirm information I have supplied is correct
DISCLAIMER OF LIABILITY: To Gore & Districts Motorcycle Club, and Motorcycling New Zealand Inc
I have read the Supplementary Regulations* for this Competition and agree to be bound by them and the Manual of Motorcycle Sport, the MNZ Constitution, and the MNZ Code of Conduct. * Supplementary Regulations also available at www.timingtech.co.nz
2. I am aware that the sport of Motorcycle Competition might a) cause me injury; serious or otherwise b) damage my property.
3. I wish to take part in the
MLT Super 6 Hour Challenge
despite the above risks.
4. Neither I, or 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.
5. 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.
6. I am physically fit and there is no health or other reason why I should not participate in the sport of Motorcycle Competition.
7. 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.
8. I agree that in this disclaimer “my property” includes any property owned by me or in my possession or under my control.
9. I agree that this disclaimer will be binding on my family, my heirs, my legal assigns and my administrators and executors.
10. I accept that stripping and re-assembly for Technical Checks are at my cost.
11. I consent to the details contained in this form being held by the
Gore & Districts Motorcycle 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. The consent is given in
accordance with the Privacy Act 1993.
12. MNZ supports the FIM/IOC Charter on drugs in Sport. MNZ uses the services of Drug Free Sport NZ & other agencies to professionally carry out the
testing. I acknowledge by signing this form I maybe subjected to a drug/alcohol test at any time. I agree to such testing. I further agree that my name
can be published by MNZ as having taken part in a drug/alcohol test together with the results of that testing.
13. I confirm that my machine complies with any technical rule(s) set out in the Manual of Motorcycle Sport and/or the Supplementary Regulations and
that, to the best of my knowledge and belief, it is in safe working order and fit for competition.
ONE EVENT LICENCE
– I do not have a MNZ Competition Licence therefore require a One Event Licence for this event:
In the absence of holding a MNZ Competition Licence, I acknowledge that I am able to compete by partaking on a One Event Licence. By reading and acknowledging this disclaimer, the Supplementary Regulations and the following rules I acknowledge that I adhere to all conditions to compete at this event using the One Event Licence.
The ability to compete whilst using a one event licence may be withdrawn at any time by Motorcycling New Zealand.
I acknowledge that I will wear an approve helmet, along with approved boots, gloves, and motocross clothing as per the MNZ Manual of Motorcycle Sport – see
I acknowledge that no drugs or alcohol are permitted at this event, and I am not under the influence of either.
I acknowledge that I may be subject to random drug & alcohol testing as per the MNZ Manual of Motorcycle Sport.
I acknowledge that I have no medical condition that prevents me from safely participating in this event. I have not suffered concussion, or a head injury in the last three weeks.
My motorcycle is in a safe operating condition and type suited to the events that I am partaking in.
I acknowledge that attending riders briefing is compulsory
It is a condition of entry that all person having any connection with promotion, organisation, and conduct of the event including land owners, will be absolved from any liability out of any accident however caused and resulting in damage to property and or in respect of death or personal injury.
I fully indemnify Motorcycling New Zealand Inc., its agents representatives, employees, contractors, other competitors and promoters from and against any liability, whether or not due to any act or omission of these parties which arises from my participation in the event including by way of example any accident, damage or injury.
I agree that I have no medical condition that prevents me from safely participating in this event. I have not suffered concussion or had a head injury in the last three weeks. I acknowledge that should I suffer a head injury or concussion three weeks prior to this event that I will not partake due the MNZ stand down period
Please make sure that you have filled out all
If your entry has been successfully submitted - this page will convert to one thanking you for your entry.
Please allow approx 20 seconds for the page to submit :
If a compulsory field has been missed the missing item will be highlighted in red.
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