MX Academy Practice Declaration

As a part of the block booking for a Champs Parc practice day it is a requirement for non NORA licence holders to complete the following form ahead of arriving at the venue for your session

This system has been put in to place following the Coronavirus outbreak, reducing the need for completing forms at an event reducing the risk of transmission of the virus.

By submitting the forom you agree to abide by the declaration as set out below:

• I fully understand the risk fo attending the site with regards to COVID-19.
• I will maintain the 2m social distancing rule whilst on site.
• I will be responsible for maintaining my own hygeine with regards to hand washing, following government guidance.
• I will comply with all instruction given to me at the venue and respect all staff and their requests.
• I will satisfy myself before taking part that the venue and track are acceptable to me with regards to their features and layout.
• By taking part I accept the risks involved in motorsport, including the risk of injury or death.
• I declare that I am competent to take part.
• I declare that I am medically fit to take part.
• I declare that my vehicle is safe, complies with the regulations and is fit to use in this competition.
• I am not taking any drugs (prescribed or otherwise) that will impair my ability to take part.
• I have read, understood and will comply with all regulations and instructions relevant for this event.
• If under the age of 18, my parent/guardian has read the above and signed opposite my name to confirm agreement with the declaration.

MX Academy Session Details

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Choose Session:
AMPM

Participant Details

Medical Declaration

Please tick the box if the answer to any question is YES.

Please answer all the questions truthfully. A false declaration may have serious consequences. If you answer 'Yes' to any of the questions, please give full details in the space provided at the end of the section. This should include the date you first developed the condition, details of any tests, investigations and any treatment you have undergone. Please include the names and addresses of any specialists you have seen and hospitals you have attended Please give full details of any medication you are taking. In completing this application, you consnt to any information concerning an injury at an event being given by the attending medical staff to the Clerk of the Course at the event.

Tick the box if you have you ever suffered from or are you curently suffering from any of the following illnesses or conditions:

Epilepsy, fits, blackouts or any condition which may cause loss of consciousness?
Any condition that might cause dizziness, vertigo or loss of balance?
Have you ever been unconscious because of a head injury or suffered from concussion?
Any brain disorder such as a stroke, MS or Motor Neurone disease?
Any loss of strength, feeling, control or movement of any of your limbs, head or neck?
Amputation of any part of your limbs with or without an artificial replacement?
Any condition involving your heart or main blood vessels or any high blood pressure?
Diabetes? If 'Yes' please state whether treated by diet, tablets or insulin?
Any psychiatric or emotional illness or any alcohol/drug/substance misuses?
Any kind of tumour or cancer?
Any condition affecting your vision or eyes, including colour blindness?
Are you taking any medication?

Please add any further information on Diabetes, medicines taken (either prescribed or bought over the counter) or any other relevant information in the box below.

Extra medical information

MOTOR SPORTS CAN BE DANGEROUS AND MAY INVOLVE INJURY OR DEATH

Read carefully before submitting to ensure that you agree.

• The answers given by me in this Licence are true.
• I fully understand the type of the events which the Licence allows me to enter and the rules and regulations that apply to such events and to competitors and will comply with them.
• I will ensure that before I enter any event, I am competent to compete and that any vehicle that I use is safe and fit for the competition and nature of the course.
• I will satisfy myself (by sighting lap or otherwise) before taking part that the venue and track is acceptable to me with regard to its features and physical layout (unless prohibited to do so).
• I will NOT enter or take part in any competition where I have a doubt as to my safety.
• I will tell you immediately if, for any reason, I believe that I am no longer able to satisfy the terms of this Licence or I become aware that I have become unable to compete due to physical or other disability.
• I agree to accept the risks of injury and death that are inherent in motor sports and agree to take part at my own risk.
• If under the age of 18, my parent / guardian has read the above and submits the form accepting the declaration and agreement.
• This Event Licence does not come with personal accident insurance cover.

Age Details

I am 18 or overI am under 18

Parent Details (if rider is under 18 years of age)