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    2019 SOUTHLAND CHAMPS ONLINE ENTRY FORM - PERMIT # 18287


    Refer Supplementary Regulations  please read as includes important information regarding event. 
    Please submit one form per competitor.
    Note: Due to insufficient entries the Junior Pro 65cc Class, Junior Ladies & Vets 50yrs & over class have been cancelled.
    Vets will now run as an all in 35 years & over class.
    Compulsory to complete all fields with an red asterick *  
    ONCE ALL FIELDS COMPLETED CLICK ON 'SUBMIT' AT BOTTOM OF PAGE TO COMPLETE YOUR ENTRY

    COMPETITOR DETAILS

    Date of birth

    If rider is under 16 years of age on race day or requires a One Event Licence & is under 18 years of age.
    Click here to read Supplementary Regulations.
    ​DISCLAIMER OF LIABILITY: To Southland Motorcycle Club, and Motorcycling New Zealand Inc. 
    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 Southland Champs 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 Southland 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 www.mnz.co.nz
    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.

    PAYMENT DETAILS AND SUBMIT ENTRY

    MAKE CHEQUES PAYABLE TO SMCC & SEND TO: 
    Southland MX Champs
    C/- Adele May
    38 Davisons Road
    NO2RD
    TIMARU 7972

    DIRECT CREDIT ENTRY FEE TO SMCC: (Include Name, & Class as a Reference)
    SMCC - 03 0931 0152483 00    

    Please make sure that you have filled out all * required fields.
    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 field "Please correct the highlighted fields" will appear below Submit Entry and the applic field will be outlined in Red
    An entry list will be posted on www.timingtech.co.nz approx. 7 days prior to event.