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LEEWOOD

LICENCE APPLICATION

Please follow the process below to apply for a National Autograss Licence and become a member of Leewood Autograss Club. This process if for new and existing membership.

If you have any club queries please contact Charlotte Carr 07507438081

NATIONAL AUTOGRASS SPORT ASSOCIATION LTD.

LICENCE APPLICATION FORM

(LEEWOOD)

By completing this form you are giving consent to Leewood Autograss Club to apply on your behalf for the issue of a NASA licence in the category you select below.

Please complete all details for the applicant (intended licence holders) and tick the "terms and conditions" box . Ensuring that you provide your signature on this application.

In addition, please tick the "medical declaration" ONLY if this applies to you.

APPLICANT DETAILS (INTENDED LICENCE HOLDER)

First Name

Last Name

Mobile number

Street address

Town/City

County

Postcode

LICENCE INFORMATION

Licence Type

Club (Automatically populated)

League (Automatically populated)

Is the applicant (Intended licence holder over the age 18 years old on the 1st February?

Date of birth required for under 18's (Before 1st February)

Age (Before 1st Feb)

Photograph of birth certificate if available

Upload File

CAR INFORMATION AND RACE NUMBER

Have you got an existing car race number?

Have you got a registered vehicle/s with a NASA rollcage tag number?

How many cars registered?

Rollcage Tag number (CAR 1)

CLASS (CAR 1)

Full Car Number including club prefix as it apppears on the car (CAR 1)

Rollcage Tag number (CAR 2)

2 CLASS

CLUB NUMBER (CAR 2)

Rollcage Tag number (CAR 3)

Choose class for (CAR 3)

Full Car Number including club prefix as it apppears on the car (CAR 3)

I have read, understood and agree to abide by the rules covering Autograss Racing as issued by the National Autograss Sport Association Ltd. (NASA) I further agree to save harmless and keep indemnified the Club, N.A.S.A. and the respective officials, members, landowners, servants, representatives and agents and / or drivers and mechanics from all actions, claims, costs, expenses, and demands in respect of loss, death or injury to myself, howsoever caused, notwithstanding that the same may have contributed to, or occasioned by, the negligence of several persons or bodies otherwise than in connection with the business or activities of the Club or NASA Ltd., and further to keep indemnified the said parties in respect of death, injury, or loss sustained by any third party as a result of the member negligence and / or breach of contract, save in so far as in either event the said liability is covered by a policy of insurance. I further realise that I shall take part in the sport of Autograss Racing entirely at my own risk.

*I accept the above terms & conditions

Tick this box if you require a wallet to be issued with your licence

Please tick this box if you have a medical condition or disability such as epilepsy, are without ar,s/legs/hands, mental or physical incapacity or failure to read a UK registration plate from 25 yards or are colour blind, and supply a suitable doctor's letter confirming that you may safely participate in Autograss Racing.

I have a medical condition as described

Please upload Doctor's letter if required for your condtion (If you are unable to do this you need to contact your club secretary before submitting your application)

Upload

IMPORTANT - Please tell us about your medical conditions

Please sign to state you agree to share your information with National Autograss Sport Association Ltd.

Applicant's Signature

*Please tick this box to confirm that you have read and understood the Parental Letter (at the bottom of this application form). Please tick this box to confirm consent for a person between the ages of 10 and 18 years old (minor) to hold any form of NASA licence, and accept the conditions of membership set out that will apply to your child as a member of NASA. If you have not, or do not agree with those terms and conditions, then do not sign this form.

Parent/Guardian Signature

Parent/Guardian Full Name

Parent/Guardian Email

Legal relationship to applicant

Have you got a different address to the applicant?

Street address

Town/City

County

Postcode

SUBMITTING YOUR APPLICATION WILL TAKE YOU TO THE PAYMENT SCREEN

(PLEASE DO NOT REFRESH YOUR SCREEN)

PARENT GUARDIAN DECLARATION.

Only the child's parent may sign this form, or such person who has been appointed by the court as guardian or foster parent of the child.

Please read the terms of this consent carefully, if you do not understand anything then ask your local Club Secretary for clarification. It is designed to create a legal relationship between you and ourselves and, by signing the document where required, you confirm that you have read this document and agree to abide by its terms and conditions and requirements.

Autograss Racing is a sport that minors may participate in with their parents' consent. It is not organised primarily for minors but their involvement is encouraged providing they and their parents understand the hazards that are associated with the sport. Motor racing is dangerous and may involve the risk of injury or death.

1. You should read and understand the current issue of the Members Handbook before signing this form. This is available in hard copy from your club secretary.
2. You, the signatory to this document, are ultimately responsible for your child at all times whether you are present at the NASA meeting with them or not and by signing this form you confirm that your child is physically fit and competent to take part in the type of events for which you are allowing him or her to participate.
3. If you do not attend any NASA meeting with your child you must arrange for a NASA Licence holding adult (over 18) who holds a Full or Mechanic's Licence to take charge of your child throughout your child's period of attendance at that meeting – including night time where applicable. You will agree that responsibility with that adult beforehand and your child is to clearly understand who their guardian is throughout the period.
4. If and when asked by a NASA official, your child will tell the official who their guardian is on the day. Failure to have a guardian present will result in your child taking no further part in the event and you being contacted and asked to remove the child.
5. You, as next of kin and person responsible will provide your name and address at the time of licence application. You are also to print this address in your child's licence in the space provided when it is issued. You will also provide two emergency telephone numbers which you will also print in their NASA licence. If this information is not in the applicant's licence then they will not be permitted to sign on to race.
6. Upon receipt your child will sign their NASA Licence and you, the same person who has signed this form will countersign.
7. You undertake to ensure that your child will carry their NASA Licence with them at all times whilst present at a NASA meeting – including evenings.
8. Your child will show any NASA official their licence upon request and without question.
9. You are to ensure that your child, if under 16 years does not drink alcohol at any time during their presence at a race meeting – day or night.
10. Your child may be breathalysed at any time of the day or evening. The procedures for testing and the penalties for failure are clearly set out in the Members' Handbook and will be applied to your child in the same way as they are to an adult.
11. You will ensure that your child's race car (where applicable) has been constructed in accordance with NASA regulations, is maintained in safe order and is built with regard to your child's size and stature and is suitable and safe to take part in the event for which that child is entered.
12. You are responsible for ensuring their seat harness; helmet and safety clothing are appropriate and maintained in good order.
13. If your child is under 16 years of age you are to ensure that they understand that they must not handle fuel or re-fuel the car. If you are not present this must be done by the child's guardian who must be present in the pit area.
14. Your child will subject their car to scrutineering with them driving the car

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LEEWOOD

LICENCE APPLICATION

LICENCE APPLICATION FORM

(LEEWOOD)

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