Licence Application Form October 2005

MOTORCYCLING AUSTRALIA NORTHERN TERRITORY

Postal: PO Box 154 Howard Springs NT 0835 Ph/Fax: 08 89832200 Mob 0417842480 Email: [email protected] Website www.mant.org.au Motorcycle Sport Membership / Licence Application

(please tick)  First time  Renewal  Upgrade 2014 Licence Fees  Senior National $290.00  Recreation only (non-competitive) per Annum $100.00  Junior National $265.00  Senior 1 Event Historic/Classic National Licence 3 $100.00  Junior National 2nd child 1 $235.00  Entrant $100.00  Junior National 3rd child 1 $205.00  Speedway Mechanic $ 35.00  Mini Licence 50cc (non competition) $100.00  Restricted 2 (see Discipline below) $200.00

Rebate fee only payable when first or second child fees has been paid Method of payment . Applicant – please print clearly  Direct Debit.  Cheque.  Money Order  Cash. Please tick. Competition Licence #. Current NT Racing No. First Name Middle Name Surname Gender  Male  Female Date of Birth / / Postal Address

Suburb Post Code

Contact Phone # Mobile Number #

E Mail Club Membership Club Sec. Signature (compulsory) (or copy of membership card)

Ambulance Fund Policy Number # Company Name (compulsory) Emergency Contact Details (next of kin in an emergency) – please print clearly

Name Phone #

What Relationship Discipline –rank preferences, by numbering.  Motocross  Enduro  Quads  Road Race  Speedway  Dirt Track  Fast 50’s 2 Super-X

For Juniors Only – please tick class(s) competing in:  50cc Mini 4-U/9  50cc 7-U/9  65cc 7-U/12  85/150cc cc 9-U/12  85/150cc 12-U/16  100cc-125cc 13-U/16  250cc 4 stroke 13-U16

 50cc Quad 5-u9  90/110cc Quad 7-u10  90/110cc Quad 9u12 90/125cc9-U13  200/300cc Quad 12/u16  Junior Road Race Make sure you have included or completed ALL of the following (please tick)  A copy of your birth certificate or extract (first time applicants only)  Ambulance Fund name & policy no.  Complete & Signed Licence testing document (first time applicant only)  Payment  Proof of Club Membership, if Club Sec. Signature not above  Junior Log Book or Extract  You have completed & signed the Indemnity over next page (or if under 18 years of age a parent or legal guardian signature) Return your completed form to: Motorcycling Australia Northern Territory Make all cheques &/or Money orders payable to MANT. NO CREDIT CARDS PLEASE. Direct Debit Banking (Commonwealth BSB 06 5901) (Account # 10208841) Receipt required please . Please turn over to next page Motorcycling Australia Northern Territory Inc PO Box 154 Howard Springs NT 0835 Ph 89832200 M 0417842480 LICENCE / MEMBERSHIP APPLICANT DECLARATION

WARNING! THIS IS AN IMPORTANT DOCUMENT WHICH AFFECTS YOUR LEGAL RIGHTS AND OBLIGATIONS, PLEASE READ IT CAREFULLY AND DO NOT SIGN IT UNLESS YOU ARE SATISFIED YOU UNDERSTAND IT.

1. I THE UNDERSIGNED (see below): - As fit for the purpose for which they are commonly disclosure of my personal information by my SCB and bought as it is reasonable to expect in the MA to other agencies and officials associated with the [Insert Name] circumstances; and conduct of Motorcycling Activities for the purposes of - Reasonably fit for any particular purpose or might conducting and managing Motorcycling Activities. I ______reasonably be expected to achieve any result you understand that I may gain access to my personal have made known to the supplier. information by contacting my SCB or MA. I understand HEREBY APPLY for a Motorcycling Australia Limited Under section 32N of the Fair Trading Act 1999, the that if I do not provide the personal information (“MA”) licence and membership. IN CONSIDERATION OF supplier is entitled to ask you to agree that these requested above that my license / membership my license / membership application being accepted, I conditions do not apply to you. If you sign this form, you application may not be accepted. acknowledge and agree that: will be agreeing that your rights to sue the supplier under 12. PERSONAL HEALTH INFORMATION 2. DEFINITIONS In this declaration: the Fair Trading Act 1999 if you are killed or injured I hereby agree with MA and the SCB that in a) “Claim” means and includes any action, suit, because the services were not rendered with due care and consideration for my membership / licence application proceeding, claim, demand, damage, cost or expense skill or they were not reasonably fit for their purpose, are being accepted that MA and the SCB may receive, however arising including but not limited to negligence excluded, restricted or modified in the way set out in this collect, store and use personal health information about but does not include a claim against a Motorcycling form. me in the manner set out below: Organisation under any right expressly conferred by NOTE: The change to your rights, as set out in this form, a) I ACKNOWLEDGE that: its constitution or regulation; does not apply if your death or injury is due to gross i) If I am injured, become ill or die at or following any b) “MA” means Motorcycling Australia Limited; negligence on the supplier's part. "Gross negligence" is Motorcycling Activity the parties providing first aid c) “State Controlling Body” (SCB) means a state or defined in the Fair Trading (Recreational Services) services at the relevant activity, in addition to any territory motorcycling association affiliated as a Regulations 2004. hospital at which I am treated, (together “my Carers”) member of MA; For the purposes of the clause 4, “the Supplier” shall will have health related information about me in their d) “Motorcycling Activities” means performing or mean and include the Motorcycling Organisations. possession, power and control relating to me which is participating in any capacity in any authorized or 6. INDEMNITY AND RELEASE subject to obligations imposed by the Privacy Act (“my recognized Motorcycling Organisation event, meeting IN CONSIDERATION of both MA and my SCB Information”) and the Privacy Act is intended to or activity; accepting my licence / membership application, I, to protect my personal information; e) “Motorcycling Organisation” means and includes the full extent permitted by law: ii) MA and my SCB wish to collect my Information for MA, and the MA members (including the SCBs and a) INDEMNIFY AND WILL KEEP INDEMNIFIED the purposes that include their risk management programs, affiliated clubs) and where the context so permits, Motorcycling Organisations and each of them in the evaluating and improving the safety of Motorcycling their respective directors, officers, members, servants following manner: Activities and generally to reduce the risks to persons or agents. i) That I participate in Motorcycling Activities at my sole engaged in motorcycle sport; and 3. MEMBERSHIP risk and responsibility; iii) It is reasonable for MA and my SCB to collect, store, use If my license / membership application is accepted I ii) That I accept the venues at which Motorcycling and disclose my Information in accordance with clause will be a member of MA, and Motorcycling Australia Activities are conducted as they stand with all or any 12(a) (i) above and in the manner set out in clause Northern Territory. I acknowledge my membership will defects hidden or exposed; 12(b). be deemed to be accepted upon my participation in iii) that I indemnify and hold harmless the Motorcycling b) IN CONSIDERATION of my membership / licence Motorcycling Activities and I acknowledge that I will be Organisations, against any actions, costs, losses or application being accepted I consent and agree that MA bound by and agree to comply with the constitutions, claims which may be made by me or on my behalf for and my SCB: regulations and policies of the Motorcycling or in respect of or arising out of my death or any i) May collect and store any of my Information, including Organisations of which I become a member. injury loss or damage caused to me or my equipment obtain my Information from third parties including my 4. ACKNOWLEDGMENT OF RISKS, DANGERS & whether caused by negligence, breach of contract or Carers; in any other manner whatsoever. ii) may use any information collected in accordance with OBLIGATIONS b) RELEASE AND WILL RELEASE the Motorcycling this clause for any purpose consistent with creating I ACKNOWLEDGE that: Organisations from all liability to me for any claim, safer competition in motorcycle sport and events held a) Motorcycling Activities are dangerous and that by loss, damage, cost or expense (whether arising under by or in conjunction with MA, my SCB, or with an MA or engaging in the sport (whether as a competitor, statute, from negligence, personal injury, SCB permit; and recreational rider, coach, official or media) at the psychological trauma, death, property damage or iii) May disclose my Information to third parties provided Meeting I take and am exposed to certain risks and infringement of third party rights or otherwise) that such disclosure is reasonably intended to be used for dangers and am under certain obligations as follows: arises as a result of any act, matter or thing done, the purpose of improving safety at events held by or in i) That I may be injured, physically or mentally, and may permitted or omitted to be done by me or which is in conjunction with MA, or with an MA permit provided any be killed; any way connected with my presence at or such information is held by MA or my SCB in ii) That my machinery or equipment may be damaged, involvement in a Motorcycling Activity. accordance with the MA Privacy Policy. lost or destroyed; 7. The release and indemnity provided by me in this c) I irrevocably authorise MA and my SCB and hereby iii) That competitors may ride dangerously or with a lack declaration is in addition to, and will not in any way appoint MA and my SCB as my lawful attorneys to of skill; limit the application of, the conditions of sale collect from my Carers, and I hereby direct my Carers iv) That track or event conditions may be hazardous and attaching to tickets, conditions of entry, conditions of to provide to MA or my SCB upon request being made may vary without warning or predictability; credentials or any other applicable terms or conditions by MA or my SCB, any of my Information including but v) that organisers, officials, landowners/track operators in respect of any Motorcycling Activity. not limited to any information concerning any incident and any agents or representatives of those in charge 8. A term of this release and indemnity will not apply or event causing or contributing to or resulting from of meetings are frequently obliged to make decisions where the term contravenes the law of the relevant any injury, illness or death to me, the details of any under pressure of time/or events; jurisdiction under which any legal action is diagnosis and prognosis provided to me by my Carers vi) That any policy of insurance of or in respect of my life legitimately taken however such terms are severable (or any party with the knowledge of any of my Carers), or physical or mental health may be voided; and do not invalidate the remaining terms. and any other matter to the knowledge of my Carers vii) That there may be no or inadequate facilities for that might reasonably be considered to be requested treatment or transport of me if I am injured; 9. MEDICAL by MA or my SCB for the purpose of improving safety at viii) That I have an obligation to myself and to others to act I declare that I am and must continue to be medically MA and SCB events. safely and within the rules and regulations of MA; and physically fit and able to participate in b) the Motorcycling Organisations, do not make any Motorcycling Activities. I will immediately notify MA in 13. POLICIES AND REGULATIONS warranty that the services associated with the writing via my SCB of any change to my fitness and I acknowledge, understand and agree that it is a provision of the Motorcycling Activities by them to me ability to participate. I understand and accept the condition of my membership that I agree to be bound will be provided with due care and skill or that any Motorcycling Organisations will continue to rely upon by, and subject to, the rules, regulations and materials provided in connection with the services will this declaration as evidence of my fitness and ability jurisdiction of MA and my SCB as amended from time to be fit for the purpose for which they are supplied; and to participate. time. Copies of all MA rules, policies and regulations c) To the extent that any warranty is implied it is 10. I acknowledge and agree that if required, the are available by contacting the MA office. excluded to the full extent permitted by law. Motorcycling Organisations (or any of them) may 14. All participants are bound by the MA anti doping policy d) I have voluntarily read and understood this warning arrange medical or hospital treatment (including and thus understand they may be subject to drug and accept and assume the inherent risks in ambulance transportation) for me. I authorise such testing. Testing conducted by the Australian Sports participating in Motorcycling Activities. actions being taken by the Motorcycling Organisations Anti-Doping Authority (ASADA) is in accordance with and agree to meet all costs associated with such the ASADA Act and the National Ant-Doping Scheme. 5. WARNING UNDER THE FAIR TRADING ACT action. I understand it is compulsory for me to have This involves the taking of a sample (any human 1999 (VIC) ambulance insurance in some form and I accept biological fluid or tissue whether alive or otherwise, or Under the provisions of the Fair Trading Act 1999 responsibility for the cost of ambulance any human breath) for the purpose of detecting the use (Vic) several conditions are implied into contracts for transportation, ambulance cover and further agree to of a Prohibited Drug or Doping Method. Any participant the supply of certain goods and services. These maintain ambulance cover during the term of my infringing MA’s policy or refusing a drug test may be conditions mean that the supplier named on this form license / membership. disqualified or otherwise dealt with in accordance with is required to ensure that the recreational services it the terms of the anti-doping policy. supplies to you are: 11. PRIVACY - rendered with due care and skill; and I hereby consent to the collection of my personal information by my SCB and MA and the use and

15. EXECUTION I THE UNDERSIGNED STATE THAT I HAVE READ AND UNDERSTOOD THIS DECLARATION (INCLUDING THE WARNING, SIGN INDEMNITY AND RELEASE) AND AGREE TO THE TERMS AND CONDITIONS AS STATED. MOTORCYCLING AUSTRALIA (MA - ABN 83 057 830 083) IS THE CONTROLLING BODY OF MOTORCYCLE SPORT IN AUSTRALIA. AFFILIATED TO FEDERATION INTERNATIONALE DE MOTOCYCLISME (F.I.M.) ACN HERE 077-842-114 Motorcycling Australia Northern Territory Inc PO Box 154 Howard Springs NT 0835 Ph 89832200 M 0417842480 NAME (PRINT):______SIGNATURE: ______DATE:______

16. THIRD PARTY INDEMNITY WHERE PARTICIPANT IS UNDER 18 YEARS OF AGE

IWE ______being the parents or guardians of the person named in Clause 1 (hereinafter called "the entrant") HEREBY ACKNOWLEDGE: a) I/we have read the whole of this document and understand it; b) I/we consent to the applicant becoming a member of MA and the relevant SCB and participating in Motorcycling Activities; AND c) I/we are aware of the risks, dangers and obligations set out in Clause 3 above; d) I/we acknowledge that the applicant is bound by and subject to the rules and policies of MA and the relevant SCB, including, without limitation, the MA anti-doping policy. . 17. IN CONSIDERATION of the applicant being accepted as a member I/WE HEREBY INDEMNIFY AND RELEASE the Motorcycling Organisations in the same manner and to the same effect as if I/WE were the applicant and agree to personally accept all terms and conditions and obligations set out in this declaration.

PARENT/GUARDIAN:______SIGNATURE______DATE:______

MOTORCYCLING AUSTRALIA (MA - ABN 83 057 830 083) IS THE CONTROLLING BODY OF MOTORCYCLE SPORT IN AUSTRALIA. AFFILIATED TO FEDERATION INTERNATIONALE DE MOTOCYCLISME (F.I.M.) ACN 077-842-114