Test If you are human, leave this field blank.ENTRY FORM2020 SUMMER AUTOCROSS SERIESPlease complete this form with all relevant details correctly formatted to ensure your entry is accepted. Supp Regs can be downloaded from the Official NoticeboardDRIVER DETAILSDRIVER *Have you competed in the Summer Autocross Series already this season?YesNoFirst Name *Surname *Street *City *State *WAACTNSWNTQLDSATASVICPostcode *Email *Mobile *CAMS Licence # *CAMS Exp Date *WA Car ClubThe Summer Autocross Series is run as a Single Club Autocross to keep the entry fees low. If you are not already a member you will need to become a member of the WA Car Club. Annual or Day memberships are available.Car Club *Are you already a current member of the WA Car Club?YesNoWACC Membership # *WACC Exp DateI need a WA Car Club Membership *Please select from the following options:Include Annual ADULT Membership @ $50Include Annual JUNIOR Membership @ $27Include Annual FAMILY Membership @ $100Include DAY Membership @ $15 per event Emergency ContactPlease provide the Name and Mobile number for your next of kin in the event of an emergency.Next of Kin Name *Next of Kin Mobile * VEHICLECAR DETAILSCAR DETAILSAre ALL your vehicle details the same as the last Autocross you have competed in THIS year?YesNoYear *Make *Model *Colour *Class *Please nominate the CLASS you will be competing in. Note: Where you qualify for more than 1 class please nominate your preferred Class as per Item 4.5 of the Supp Regs.Class 1 - 4WDClass 2 - 2WDClass 3 - NoviceClass 4 - Off RoadClass 5 - LadiesClass 6 - JuniorCross Entered CarIf you are sharing your car with another driver or drivers please provide their names below to assist us when generating the start order. Note: A maximum of 3 drivers per car and EACH driver will need to complete an entry form.PAYMENTPAYMENT DETAILSReminder: Your Entry Fee must be received in full prior to close of entries in order for your entry to be accepted.EventsSelect all round(s) of the series that you intend to compete in. Payment can be made on an event by event basis, however the entry fee MUST be received prior to the close of entries for each individual event.Round 1 - 6th November 2019Round 2 - 11th December 2019Round 3 - 22nd January 2020Round 4 - 26th February 2020Round 5 - 18th March 2020Payment Type *Please select your preferred payment method.Direct DepositCredit CardENTRY FEESADULT entry fee: $100JUNIOR entry fee: $80WA Car Club DAY Membership: $15WA Car Club ADULT ANNUAL Membership: $50WA Car Club FAMILY Membership: $100WA Car Club Junior ANNUAL Membership: $27Direct Debit DetailsBSB: 306055 Account #: 4195765 Ref: AX20 & Drivers Surname Credit CardPlease contact firstname.lastname@example.org to arrange a Credit Card Payment. Please note a 1.5% Admin Fee applies to all Credit Card payments. Tax InvoicePlease advise the business name should you require a Tax Invoice to be supplied. Leave blank if an invoice is not required.MOTORPLEX DISCLAIMERMotorplex DisclaimerPARTICIPANT’S ACKNOWLEDGEMENT OF RISK STATEMENT INCLUDING WAIVER, RELEASE & INDEMNITY This Participant’s Acknowledgement of Risk Statement including Waiver, Release & Indemnity (“Indemnity”) affects your legal rights and obligations. Read it carefully and do not sign it unless you are satisfied that you understand it. If you have any questions please ask a representative of the Operator. THE OPERATOR: Western Australian Sports Centre Trust t/as VenuesWest (“VenuesWest”) and its authorised, officers, agents, employees and THE ACTIVITY: Drag Racing, Speedway, other Motorsport events and related activities at Perth Motorplex (“Venue”) THE ASSOCIATED ENTITIES: The State of Western Australia and controlling bodies, promoters and sponsor organisations of the Activity, organisers of the Activity, land owners and lessees of the Venue and their respective employees, officials, representatives and THE RISKS OF THE ACTIVITY: The Activity is dangerous and involves risks of personal injury (including illness), psychological trauma and death and damage to and destruction of personal property, including due to the following risks: Risk of being hit by a vehicle or hitting another vehicle Risk of being hit by debris from vehicles or surfaces Risk of colliding with safety barriers/fencing or other fixed or moveable objects Risk of safety barriers/fencing or other facilities of the Venue failing Risk of crashing due to the surface of the track Risk of being burnt Risk of crashing due to debris on the track Risk of slipping and falling Risk of injury through acts of violence or other harmful acts committed by person attending or participating in the Activity ACKNOWLEDGEMENTS: I acknowledge and accept that: a) I am the participant in the Activity b) I am being supplied with a recreational service by the Operator (as that term is defined in the Competition and Consumer Act 2010 (Cth) and the Consumer Law (WA)) and the Activity is a recreational activity and a dangerous recreational activity (as those terms are defined in the Civil Liability Act 2002 (WA)), which involves a significant risk of physical harm. Those laws impact the legal rights I might otherwise have in relation to the Activity. c) I may be injured as a result of my participation in the Activity. d) My personal property and property in my care and control may be lost, damaged or destroyed as a result of my participation in the Activity. e) Other people may cause me injury or may damage my property, or property in my care and control, in the course of my participation in the Activity. f) I may cause injury to myself or other persons or damage my property or the property of others in the course of my participation in the Activity. g) The natural conditions in which the Activity is conducted may vary without warning which may affect the safety of the Activity. h) My participation in the Activity is voluntary and I have not been required by the Operator to engage in the Activity. i) I have disclosed any pre-existing medical or other condition that may affect the risk that either I or any other person may suffer in connection with my participation in the Activity. j) The Operator relies on the information provided by me and I state that all such information provided is accurate and complete. k) I am not, and will not during the Activity, be under the influence of any alcohol, mind altering substances, drugs or other substances which may impair my judgment or physical ability or capacity to safely participate in the Activity and I accept full responsibility for any injury, loss or damage associated with my consumption of alcohol, mind altering substances, drugs or other substances which impairs my judgment, physical ability or capacity to safely participate in the Activity. l) I have not relied upon any advice, representations or inducements by or on behalf of the Operator in deciding to participate in the Activity or in deciding to sign this Indemnity. m) I will comply with the Conditions of Entry and Conditions of Sale, copies of which are available at motorplex.com.au. MEDICAL DECLARATION: I declare that I am not subject to any existing injury, medical condition, medication or treatment that may render me unsuitable for participating in the Activity. RISK WARNING: This risk warning is given on behalf of the Operator and each of the Associated Entities: a) I acknowledge that I have been warned of the risks of the Activity b) I acknowledge that participation in the Activity may involve other risks not noted in the risks of the Activity listed in Section 3 above c) The Operator has placed signs at the Venue warning of the risks of the Activity, including the risk of injury, physical and psychological harm and I have read the signs and understand the warnings provided. d) The Operator and the Associated Entities have provided me with warnings of the risks associated with the Activity and the risks of physical or psychological harm or death in connection with attending and participating in the activity ASSUMPTION OF RISK Notwithstanding the significant risks of psychological trauma, physical harm, injury, illness and death inherent in the Activity, some of which are noted above, I agree that I attend and participate in the Activity at my own risk. WAIVER, RELEASE AND INDEMNITY: I agree, to the extent permitted by law: a) to release, indemnify and hold harmless the Operator and the Associated Entities from and against any and all Loss which I or any other person may suffer or incur whether directly or indirectly, from or in connection with: i) my participation in or attendance at the Activity; and ii) my use of or presence at the Venue, including any loss of, damage to or theft of my property; and iii) any act or omission on the part of the Operator or any of the Associated Entities; and b) that the Operator and the Associated Entities do not make any warranty, implied or express, that any services for or in connection with the Activity or the Venue will be provided with due care and skill or that any materials provided in connection with the Activity will be fit for the purpose for which they are supplied MISCELLANEOUS a) I agree to comply with all rules, regulations and directions made or given by the Operator and the Associated Entities in connection with the Activity. I understand that if I fail to comply with the rules or directions of the Operator and the Associated Entities, I may be injured or injure someone Further I understand that if I fail to comply, I will not be permitted to continue the Activity and no refund will be given. b) I agree to comply with all relevant laws, rules and regulations of the Confederation of Australian Motor Sport (“CAMS”) in relation to the Activity and I confirm that I hold all licences required by CAMS for the activity c) I agree to report all accidents, injuries or loss or damage sustained by me to the Operator before I leave the Venue on the day of the Activity d) I agree that if I suffer any injury or illness the Operator may provide or arrange evacuation, first aid and medical treatment at my expense e) I understand that this Indemnity is not intended to exclude any valid claim I may have under the CAMS Personal Insurance Scheme f) I confirm that I am either: (i) over the age of 18 years of age; or (ii) under the age of 18 years of age and my parent or legal guardian has signed a Perth Motorplex “Consent Statement For Participants Under 18 Years”. g) I confirm that I am either: (i) the registered owner of the motor vehicle to be used in the Activity; or (ii) I am not the registered owner of the motor vehicle to be used in the Activity and the registered owner has signed the Perth Motorplex “Consent Statement to Use Motor Vehicle”. SOCIAL MEDIA: The Operator encourages participation in online social media in a positive manner with freedom of expression. The accessible nature of the Internet however, can lend itself to the posting of threatening and derogatory material in the heat of the moment. Once your thoughts and comments are published to the Internet they are visible to the world – and they are permanent. The Operator takes all cases of threatening and derogatory behaviour seriously and will treat online matters as it would ‘real world’ bullying. Instances of posts not in the best interest will be dealt with in an appropriate manner. Serious consequences including a loss of racing privileges may be enforced for those who participate in bringing the Operator and the Perth Motorplex and its participants into disrepute. NOTE: The Operator and the organisers reserve the right to change/alter entry to race procedure at any time as deemed necessary. The Operator also reserves the right to use images of entrants, riders and drivers and their vehicles in a variety of media used for the promotion of events at Perth Motorplex I ACKNOWLEDGE THAT I HAVE READ THE INDEMNITY WARNING ME OF THE RISKS OF MY PARTICIPATION IN THE ACTIVITY. I UNDERSTAND THE TERMS OF THE INDEMNITY AND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING THE INDEMNITY I SIGN THE INDEMNITY FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT MADE TO ME Motorplex Disclaimer *Yes, I accept the Motorplex DisclaimerCAMS DISCLAIMERCAMS DisclaimerRISK WARNING AND ASSUMPTION OF RISK 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 & INDEMNITY In exchange for being able to attend or participate in Motor Sport Activities, I agree: to release CAMS 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 CAMS 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 CAMS and the Entities as the supplier of Motor Sport Activities / 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 CAMS insurance policy where I am expressly entitled to make a claim under that insurance policy; and CAMS 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 CAMS 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 CAMS insurance arrangements, this document and my own circumstances. CAMS Disclaimer *Yes, I accept the CAMS DisclaimerSUBMIT ENTRYSUBMIT YOUR ENTRYThank you. Please check the boxes below and then click the Submit button once to complete your entry. A confirmation page will appear shortly.Confirmation *I have read and understand the event Supplementary RegulationsI understand that payment must be made in full prior to close of entries at each roundI acknowledge that the information provided above is true and correctSubmitCAPTCHA *reCAPTCHA is required.