P.O. Box 303
Berowra N.S.W. 2081
APPLICATION FOR KICK START & MEMBERSHIP OF HORNSBY JUNIOR DIRT BIKE CLUB
New Member - Kick Start Program
Parent / Guardian details
Surname:First Name:
Address:
State / Post Code:
Telephone # / Home: / Mobile: / Work:
Email:
Kick Start Program * 15th of March 2015
Item / Fee / Number off / Total
Club Membership *
Includes club jersey / $70.00 Per Rider
Kick start program* / $30.00 Per Rider
Daily Ride fee / $25.00 Per Rider
Total / $125.00 Per Rider
Total fee due.
Riders details
Name / Date of Birth
Bike – Make and model / 85 / 150cc wheel Size
Rider Number
Medical Conditions
Riders details
Name / Date of Birth
Bike – Make and model / 85 / 150cc wheel Size
Rider Number
Medical Conditions
HJDBC Banking Details
(do not make any payments to this account that are for MCNSW licencing applications / endorsements upgrades and licence renewals)
Account Name
HORNSBY JUNIOR DIRT BIKE CLUB
Commonwealth Bank of Australia
BSB062-714
Account Number 010-009-467
Payment required before the day to confirm your position on the day. – No Exceptions
Indemnity
In consideration for the HJDBC providing the facilities and permitting my child / children to ride with in the clubs grounds located at the end of Beaumont Road Mt Kuring - Gai held by the HJDBC inc. By way of lease from Hornsby Shire Council (Or any other land legally used by the club).
I/WE HEREBY for myself/ourselves and my/our said child/children AGREE AND DECLARE that my/our child/children use of such facilities shall be on the following conditions:
1. That the club shall not be responsible for any injury suffered to me/us or my/our child/children in using the facilities and I/we accept full responsibility for my/our safety and that of my/our child/children.
2. I/We indemnify the HJDBC Inc., its officials, members, eligible voters and the Hornsby Shire Council from all claims, as a result of any injury suffered by me/us or my/our child/children in suing the aforementioned facilities.
A. as a result of any damage to, destruction of, or loss of motorbikes and/or personal belongings.
3. I/We acknowledge all private information collected will be used for the sole purpose of administration club
activities only and will remain confidential.
Medical care – I hereby authorise any track or club official to seek out on my behalf any medical care, hospitalisation or to render what first aid orto enlist whatever medical or other care they may feel is necessary in the event of any accident, if not in my own attendance at the time of theinjury to any son/daughter/ward/relative so named, or to my own person if circumstances are such that my own decision cannot be readily sought.
I further authorise the Club, through its officiate, to authorise any surgical or medical procedure, operation, drug medication, x-ray orother medical or lifesaving procedure that may be dictated by the circumstances and supported by medical opinion, and their individualassessment of the injury.
They are further authorised and held free from personal liability for any expenses, fees or damages howsoever and in whatsoever manner
SIGNED: SIGNED:(Parent/Guardian) (Witness)
Date:____/____/______