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SS SURVEY 2019
HASLER MEMORIAL MX ONLINE ENTRY
5th August 2018 at Riverside Reserve, Balclutha
- Permit #17292
for available classes & important event information
Please submit a seperate entry for each competitor.
Ensure you complete all sections and enter 'Submit' at the bottom of the page
Indicates required field
Select Class from Drop down list
Mini Intro 4-6yrs (not lapscored - beginners)
Mini 4-6yrs MX 50cc (10 inch)
Mini 6-8yrs MX 50cc (12 inch)
Mini 7-11yrs 65cc MX
Mini 6-11yrs Trail (max 125cc 4 st air cooled)
8-11yrs 60-85/150cc (Min 9 yrs to ride 150cc)
12-16 yrs 85/150cc
12-16yrs 125cc 2 st + 14-16yrs 250cc 4 st (one class)
MX1 (includes 250cc 2 Stroke)
Enduro/Clubman (for novice/non competitive riders)
Machine & Capacity
Date of birth
Age on race day
2nd Class Race Number
2nd Class entered
12-16 yrs 85/150cc
12-16yrs 125cc 2 st + 14-16yrs 250cc 4 st
MX1 (includes 250cc 2 Stroke)
Enduro/Clubman (for Novice/non competitive riders)
Vets (All iin)
2nd Class Machine & Capacity
MNZ Licence # or OE if One Event Licence Required
Mini Intro Entry Fee (Not lapscored) $20.00
Mini Lapscored Entry Fee $40.00
Junior/Senior Entry Fee $70.00 (1st Family member)
2nd class/family member Deduct $10.00 from additional entries), No Family discounts for Mini Intro as already reduced
One Event Licence Required $30.00
Own Transponder (provide pin number) Deduct $5
Late Entry Fee (Applicable for day entries)
Late Entry Fee - $20.00
Intended Payment Method
Cheque Being Sent
Total Payment $
Comments/Queries or TX Pin #
DISCLAIMER OF LIABILITY: To South Otago Motorcycle Club, and Motorcycling New Zealand Inc.
I have read and understood the Supplementary Regulations for this competition and agree to be bound by them and the Manual of Motorcycle Sport of Motorcycling New Zealand Inc. Together with the terms of the indemnification hereunder, and the requirements of the Noise Restrictions as listed. I indemnify Christchurch Off-road Motorcycle Club Motorcycling New Zealand Inc., Local Bodies and Landowner, their agents and all Officials against any claims arising from my attendance at this meeting.
1. 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
Hasler Memorial MX
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
South Otago 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 and 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.
If rider is under 16 years of age on race day or under 18 years & requires a One Event Licence, form must be completed by Parent/Legal Guardian
Parent/Legal Guardian Name (who will be present on race day)
to see the terms and conditions (Supplementary Regulations)
I have read and accepted Terms and Conditions (Disclaimer above) and I enter at my own risk
I confirm information I have supplied is correct
Cheques payable to – South Otago Motorcycle Club, and post to
Hasler Memorial MX
C/- Adele May
38 Davisons Road
Direct Credit – SOMCC
03 - 1734 - 0006211 - 00
(Please include class & name as ref)
Please make sure that you have filled out all
Your entry has been sucessfully submitted if this page converts to one thanking you for your entry
(Allow approx 20 seconds to submit)
If you have missed a compulsory field then it will remain on this page and be highlighted in red.
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