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The Cloverleaf Rallies - November 21, 2009
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West Essex Car Club Limited Cloverleaf Historic Rally Cloverleaf Clubmans Rally November 21, 2009 New Entry Form Held under the General Regulations of the Motor Sports Association (incorporating the provisions of the International Sporting Code of the FIA) and these Supplementary Regulations

Entry Number		Start Number

Which event are you entering?	Historic Clubmans

Entrant/ Main Sponsor	Name
	Licence No

	Driver	Navigator
Full Name
Address
Mobile Tel No
Evening Tel No
Licence No.
Club
Email
Age (if under 18)

Championships	HRCR	HRCR

Parent or Guardian name, relationship and address details if under 18.
	Under 18 competitors please download and action the Consent Form
Person to be contacted in the event of a serious accident - name, relationship, address, telephone no
Main Contact:	Post to Driver Post to Navigator Email to Both

Car	Make & Model Reg. No.
	Engine cc Year Colour

Class	Historic: 1 2 3 4 5 6 Clubmans: Master Expert Novice

Insurance	a) I shall be using my own insurance. The name and address of my insurer is:
	b) I shall be using the Lockton (Alexander Forbes) scheme and can sign the declaration at signing-on. (See SR 21)
	c) I wish to use the Lockton (Alexander Forbes) scheme and require a proposal form as I will be unable to sign the declaration at signing-on. (See SR 21)


Scrutineering	I shall attend on: Friday Evening 17:00-19:00 Saturday Morning 07:15-08:15
	I will need space for a trailer: Yes / No
	I shall require a waiver in accordance with GR H123 because …

Seeding	The organisers don’t believe seeding other than by ability is strictly necessary on regularity events, but if you have any particular requirements we will try to accommodate you.

Fees	Entry Fee (Historic £110.00, Clubmans £100.00)		£
	WECC Club Memberships - 0 1 2		£
	Lockton Insurance (£15.50 with no loading)		£
	Multiple Sclerosis Society Donation (THANK YOU)		£
	Total Remittance Please make cheques payable to WEST ESSEX CAR CLUB Limited		£

Declarations	DECLARATION OF INDEMNITY 1. I declare that I have been given the opportunity to read the General Regulations of the Motor Sports Association and, if any, the Supplementary Regulations for this event and agree to be bound by them. I declare that I am physically and mentally fit to take part in the event and I am competent to do so. I acknowledge that I understand the nature and type of the competition and the potential risk inherent with motor sport and agree to accept that risk. Further, I understand that all persons having any connection with the promotion and/or organisation and/or conduct of the event are insured against loss or injury caused through their negligence. 2. I declare that to the best of my belief the driver(s) possess(es) the standard of competence necessary for an event of the type to which this entry relates and that the vehicle entered is suitable and roadworthy for the event having regard to the course and the speeds which will be reached. 3. I declare that the use of the vehicle hereby entered will be covered by insurance as required by the law which is valid for such part of this event as shall take place on roads as defined by the law. 4. I understand that should I at the time of this event be suffering from any disability whether permanent or temporary which is likely to affect prejudicially my normal control of my vehicle, I may not take part unless I have declared such disability to the ASN which has, following such declaration, issued a licence which permits me to do so. 5. Any application form for a Licence which was signed by a person under the age of 18 years was countersigned by that person's parent/legal guardian/guarantor, whose full names and addresses have been given. 7. I hereby agree to abide by the MSA Child Protection Policy and Guidelines. By submitting this form the Driver and Navigator or their Parent/Guardian agrees with the above declarations.

	6. I understand that I shall have the right to be present during any procedure being carried out under the Supplementary Regulations issued for this event and the General Regulations of the MSA. I confirm that I have acquainted myself with the MSA General Regulations, agree to pay any appropriate charges and fees pursuant to those Regulations (to include any appendices thereto) and hereby agree to be bound by those Regulations and submit myself without reserve to the consequences resulting from those Regulations (and any subsequent alteration thereof). Further, I agree to pay as liquidated damages any fines imposed upon me up to the maxima set out in Part 3, Appendix 3. By submitting this form the Parent/Guardian of the Driver and/or Navigator agrees with above declaration.

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