Rover Scout Motorsport Western Australia

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1 Bush Baja 2015 Northam, WA. Rover Scout Motorsport Western Australia Event Entry Form Khanacross/Motorkhana Event Date: 29/5/15 1/6/15 Khanacross to be held under the International Sporting Code of the FIA, and the National Competition Rules of CAMS Note: This form replaces the requirement of a Scout A3 Form PERSONAL DETAILS Surname: Given Names: Date of Birth: Scout Group: Scout Section: Leader Responsible: Scout Membership Number: Address: Suburb: State/Postcode: Mobile Phone: Home Phone: Address: Working With Children Card #: Working With Children Card Expiry Date: EMERGENCY CONTACTS Name: Relationship: Home Phone Number: Mobile Phone Number: Work Phone Number: Name: Relationship: Home Phone Number: Mobile Phone Number: EMERGENCY CONTACT 1 EMERGENCY CONTACT 2 Page 1 of 6

Competition Rules of CAMS Note: This form replaces the requirement of a Scout A3 Form PERSONAL DETAILS Surname: Given Names: Date of Birth: Scout Group: Scout Section: Leader Responsible: Scout

2 HEALTH STATEMENT MEDICATION Please provide details of medication the applicant will be taking during the activity: Type/Name: Dosage: Frequency of Dose: DIETARY REQUIRMENTS Please provide details of any dietary requirements: ALLERGIES/AILMENTS/DISABILITIES Please provide details of any allergies, ailments or disabilities: IMMUNISATION Has the applicant been immunised against Tetanus in the past 5 years? (Please Tick) YES NO If not, can the applicant be given a Tetanus injection should the need arise? YES NO Medicare Number: Health Fund: Health Fund Number: Ambulance Fund Number: Page 2 of 6

allergies, ailments or disabilities: IMMUNISATION Has the applicant been immunised against Tetanus in the past 5 years?

3 A3 - CONSENT TO ATTEND AN OVERNIGHT SCOUT ACTIVITY ACCEPTANCE I give permission for the applicant to attend the activities / events (marked YES) and for the Leader in Charge of the activity / event to seek medical assistance for the applicant should the need arise. I have supplied the Leader in Charge with an Annual Health Statement for the applicant and agree to notify the Leader in Charge should any changes occur with the health of the applicant. Applicant Signature (if over 18 years): Parent/Guardian Signature (if under 18 years): Date:.. *NOTE: EVERYONE MUST SIGN* *NOTE: EVEN IF NOT RACING, PLEASE CONTINUE MUST SIGN FURTHER ON IN DOCUMENT* RSM & CAMS MEMBERSHIP DETAILS (if applicable leave blank if unknown) CAMS Affiliated Car Club: CAMS Licence Number: CAMS Licence Grade: CAMS Drivers Licence Expiry: CAMS Officials Licence Expiry: RSM Membership Number: Rover Scout Motorsport - WA DRIVER & OFFICIALS DISCLAIMER EXCLUSION OF LIABILITY, RELEASE AND ASSUMPTION OF RISK For Competitors COMPETITORS AND/OR DRIVERS Version June 2009 I/We being the competitor/s of the vehicle described on this Entry Form wish to enter that vehicle for the above event. For Competitors and Drivers I/We being the competitor/s and/or driver, certify that the particulars on this form are true and correct in every particular, to the best of my/our knowledge and belief. I/We declare that I/we have read and understood the Supplementary Regulations issued for the event, and agree to be bound by them and the provisions of the National Competition Rules of the Confederation of Australian Motor Sport Limited ( CAMS ). Page 3 of 6

I have supplied the Leader in Charge with an Annual Health Statement for the applicant and agree to notify the Leader in Charge should any changes occur with the health of the applicant.

4 In exchange for being able to attend or participate in the event (including entering the event), I agree: to release CAMS and Australian Motor Sport Commission Ltd, the Scout Association of Australia Western Australian Branch, promoters, sponsor organisations, land owners and lessees, organisers of the event, their respective servants, officials, representatives and agents (collectively, the "Associated Entities") from all liability for my death, personal injury (including burns), psychological trauma, loss or damage (including property damage) ("harm") howsoever arising from my participation in or attendance at the event, except to the extent prohibited by law; that CAMS and the Associated Entities do not make any warranty, implied or express, that the event services will be provided with due care and skill or that any materials provided in connection with the services will be fit for the purpose for which they are supplied; and to attend or participate in the event at my own risk. I/we acknowledge that: the risks associated with attending or participating in the event include the risk that I may suffer harm as a result of: motor vehicles (or parts of them) colliding with other motor vehicles, persons or property; 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 the safety of persons or property at the event. motor sport is dangerous and that accidents causing harm can and do happen and may happen to me. I accept the conditions of, and acknowledge the risks arising from, attending or participating in the event and being provided with the event services by CAMS and the Associated Entities. I understand that this disclaimer is not intended to exclude any valid claim I may have under the CAMS Personal Insurance Scheme. To be completed by Participant Competitor/Driver/Officials s Signature:... Date:... *NOTE: EVERYONE MUST SIGN* *NOTE: EVEN IF NOT RACING, PLEASE CONTINUE MUST SIGN FURTHER ON IN DOCUMENT* Page 4 of 6

"Associated Entities") from all liability for my death, personal injury (including burns), psychological trauma, loss or damage (including property damage) ("harm") howsoever arising from my

5 PASSENGER DISCLAIMER EXCLUSION OF LIABILITY, RELEASE AND ASSUMPTION OF RISK PASSENGERS IN VEHICLES Version December 2006 In exchange for being able to attend the circuit or activity location and ride as a passenger in a vehicle (whether during a motor sports event or otherwise), I agree: to release Confederation of Australian Motor Sport Ltd ("CAMS") and Australian Motor Sport Commission Ltd, the Scout Association of Australia Western Australian Branch, promoters, sponsor organisations, land owners and lessees, organisers of the event, their respective servants, officials, representatives and agents (collectively, the "Associated Entities") from all liability for my death, personal injury (including burns), psychological trauma, loss or damage (including property damage) ("harm") howsoever arising from my attendance at the circuit and riding as a passenger, except to the extent prohibited by law; that CAMS and the Associated Entities do not make any warranty, implied or express, that the event services will be provided with due care and skill or that any materials provided in connection with the services will be fit for the purpose for which they are supplied; and to attend the circuit or activity location and ride as a passenger at my own risk. I acknowledge that: the risks associated with attending the circuit or activity location and riding as a passenger in a vehicle (whether during an event or otherwise) include the risk that I may suffer harm as a result of: motor vehicles (or parts of them) colliding with other motor vehicles, persons or property; 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 the safety of persons or property at the event. motor sport is dangerous and that accidents causing harm can and do happen and may happen to me. I accept the conditions of, and acknowledge the risks arising from, attending the circuit or activity location and riding as a passenger and being provided with services by CAMS and the Associated Entities. To be completed by Participant Signed:... Date:... *NOTE: EVERYONE MUST SIGN* Page 5 of 6

Scout Association of Australia Western Australian Branch, promoters, sponsor organisations, land owners and lessees, organisers of the event, their respective servants, officials, representatives and

6 For persons under the age of 18 years the following parent/guardian consent must be completed. PARENT/ GUARDIAN CONSENT PERSONS UNDER 18 YEARS OLD I of [Address] am the parent/ guardian* of the above-named ("the minor") who is under 18 years old. I have read this document and understand its contents, including the exclusion of liability and assumption of risk, and have explained the contents to the minor. I consent to the minor attending/ participating in* the event at his/her own risk. Signed Date Parent/Guardian* * Delete whichever does not apply Please Return to: In person: Angela Graham, Bush Baja Admin angelagraham@westnet.com.au rsm.president@warovers.com.au Page 6 of 6

I have read this document and understand its contents, including the exclusion of liability and assumption of risk, and have explained the contents to the minor.

NDN15 SUPERSPRINT ZCAR CLUB Q INC. MORGAN PARK RACEWAY 3-5 APRIL 2015 SUPPLEMENTARY REGULATIONS

NDN15 SUPERSPRINT ZCAR CLUB Q INC. MORGAN PARK RACEWAY 3-5 APRIL 2015 SUPPLEMENTARY REGULATIONS ZCAR CLUB Q INC. NDN15 SUPERSPRINT MORGAN PARK RACEWAY 3-5 APRIL 2015 SUPPLEMENTARY REGULATIONS AUTHORITY: This event is held under the International Sporting Code of the FIA and the National Competition