NATIONAL AUTOGRASS SPORT ASSOCIATION LTD.
LICENCE APPLICATION FORM
By completing this form you are giving consent to Penhow 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)
CAR INFORMATION AND RACE NUMBER
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.
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.
Please sign to state you agree to share your information with National Autograss Sport Association Ltd.