2012 LICENCE & MEMBERSHIP APPLICATION FORM
2012 LICENCE APPLICATION & MEMBERSHIP FORM
INSURANCE DETAILS (International Licences Only)
BMX riders are not required to take out a UCI international licence to race overseas unless they are competing in elite UCI events (e.g. supercross, world cups). BMX riders must be licensed appropriately through their local club in order to compete overseas at non-elite UCI events (e.g. age-group world championships). Please contact BMXNZ direct for more information on getting a BMX licence: Christine Misa, .
BikeNZ offers riders from its member organisations, including BMXNZ, the option to purchase travel insurance that covers them while they are training and racing overseas. Racing activities are usually excluded from travel insurance policies. It is strongly advised you check the premiums and policy details on the BikeNZ website before purchase (http://www.bikenz.org.nz/Article.aspx?ID=1525). The policy details are also summarised below.
Period Outside NZ / PLAN A:Travel Insurance Only –
WorldWide Cover* / PLAN B:
Travel Insurance only – Worldwide Cover excluding USA, Canada and Europe (not including the UK)*
Up to 8 Days / 1a / $304 / 1b / $224
Up to 15 Days / 2a / $332 / 2b / $247
Up to 30 Days / 3a / $468 / 3b / $383
Up to 60 Days / 4a / $810 / 4b / $690
Up to 90 Days / 5a / $1140 / 5b / $1036
Up to 120 Days / 6a / $1164 / 6b / $1057
Up to 150 Days / 7a / $1197 / 7b / $1088
Up to 6 Months / 8a / $1232 / 8b / $1118
Up to 7 Months / 9a / $1436 / 9b / $1306
Up to 8 Months / 10a / $1642 / 10b / $1492
Up to 9 Months / 11a / $1846 / 11b / $1678
Up to 10 Months / 12a / $2052 / 12b / $1864
Up to 11 Months / 13a / $2256 / 13b / $2052
Up to 12 Months / 14a / $2459 / 14b / $2236
* Note: Premiums exclude bike cover
Plan A: Worldwide Cover
This plan will provide travel cover for BikeNZ riders travelling anywhere in the world to compete in cycling events.
Plan B: Worldwide Cover excluding USA, Canada, Europe (which does not include the UK)
This plan will provide travel cover for BikeNZ riders travelling anywhere including the UK but not USA, Canada and/or Europe to compete in cycling events. If you are going to the UK, but not the rest of Europe, you may purchase this plan.
Bike Cover Option
To obtain Bike Cover riders will be charged an additional premium on top of the Plan A or Plan B premium they are paying from the table above.Refer to the website www.bikenz.org.nz for full details and limitations of bike coverage. The Bike Cover premium is calculated as follows: Sum Insured (Declared Value ($) of Bike and Accessories to be insured for) x 2%(minimum premium $150)
Excess for Bike Cover claims: $1000 or 10% of Sum Insured, whichever is greater. Any damage to bike equipment whilst racing or training is not covered – even when separately insured.
Maximum cover for Bikes and Accessories packaged in a cardboard box is limited to $5,000 or total value declared, whichever is lesser.
Maximum cover for Bikes and Accessories packaged in a hard case box is limited to $15,000 or total value declared, whichever is lesser.
If additional insurance is required after the issue of the original International Licence, application should be made directly to the BikeNZ office, advising the new period of cover required, including the appropriate additional insurance portion for the new period. Contact to arrange for an insurance extension.
2012 LICENCE APPLICATION & MEMBERSHIP FORM
Insurance cover will include the following:
Overseas Medical $Unlimited
Death & Capital Benefits $150,000
Baggage (limit per item $2500) $20,000
Money $5,000
Loss of Deposits $20,000
Auto Rental Damage & Theft Waiver $5,000
Personal Liability $2,500,000
- only $1m whilst racing & training
Kidnap / Ransom $250,000
All options cover the following
· Full terrorism cover
· The excess for all claims excluding training and competition will be $250.
· The excess for any claim for an incident whilst training or in competition will be $500.
· Personal Effects up to a maximum of $20,000 per person, with a limit $2500 any one item.
2012 LICENCE APPLICATION & MEMBERSHIP FORM
BikeNZ reserves the right to charge an urgent processing fee of $30 for international licence applications received less than 10 working days prior to departure.
MEMBER ORGANISATION / BMXNZ / New Member o or 2011 Licence Number: ______In applying for membership I agree to the personal information specified in this form being collected, held, disclosed and used for the purposes set out in this form. I understand that if I do not complete all of this section my application for membership cannot be processed.
PERSONAL DETAILS
GIVEN NAME / SURNAMEPOSTAL ADDRESS Street / PHYSICAL ADDRESS
Suburb/RD / (if different from postal)
Town
Postcode
PHONE Home / ( ) / Cell
AFFILIATED CLUB
DATE OF BIRTH (da/mo/yr) / / / / GENDER / Male / Female
SPONSORS (25 characters max) / ______
LICENCE TYPE Please circle
INTERNATIONAL(plus insurance)
$50
LICENCE CATEGORY (Race age category)
Elite / National Series Elite Riders and International Licences OnlyUnder 19 / Born 1 January 1994 – 31 December 1995 (17-18 yrs)
Senior / Born 1 January 1983 – 31 December 1989
(23-29 yrs)
TECHNICAL See description on page 1 for details on technical licence fees applied by MTBNZ.
oCommissaire / oCoach / oManager / oMechanic / oSoigneur / o Other ______INSURANCE DETAILS – for international licence purchases
UCI requirements state that insurance must be included with the cost of an International Licence. The cover provided will be restricted to your period outside New Zealand.
Date of Departure: ______Date of Return To NZ: ______Insurance Option Required: ______Declared Value of Bike : ______
(Optional See page 2)
2012 LICENCE APPLICATION & MEMBERSHIP FORM
DECLARATION
I, the person who has applied to BikeNZ and either BikeNZ Road & Track, BMX or MTBNZ for a Licence and to become a member of my Member Organisation:
1. Declare that:
(a) I am not aware of any reason why I should not be issued with the licence requested;
(b) I have not applied for a licence for the same year to the International Cycling Union (UCI) or to any other national cycling federation;
(c) I assume exclusive liability for this application and for the use I will make of the licence.
2. Undertake to:
(a) return my licence immediately in the event of any substantial change to the circumstances existing at the time of this application;
(b) comply with the constitutions, regulations, policies, manuals, guidelines and reasonable directions of BikeNZ, my Member Organisation and the UCI ;
(c) participate in cycling competitions and events in a fair and sporting manner;
(d) submit to disciplinary measures taken against me by BikeNZ, my Member Organisation or the UCI and take any appeals and litigation before the authorities provided for in the Constitution or Regulations of BikeNZ, my Member Organisation or the UCI;
(e) accept the Judicial Panels established by BikeNZ and my Member Organisation , the New Zealand Sports Disputes Tribunal and the Court of Arbitration for Sport (CAS) as the only competent jurisdictions in cases provided for by the Regulations of BikeNZ, my and UCI and that, in the case of CAS, its decisions will be final and binding and not subject to further appeal;
(f) subject to paragraph (e), submit any litigation with the UCI exclusively to the tribunals at UCI headquarters.
3. Undertake to comply with the Anti-Doping Policies of BikeNZ and my Member Organisation, the UCI Anti-Doping Regulations, the clauses of the World Anti-Doping Code and its International Standards to which the UCI Anti-Doping Regulations refer, as well as the anti-doping regulations of other competent bodies as per the UCI Anti-Doping Regulations and the World Anti-Doping Code, provided that those regulations comply with the World Anti-Doping Code. I accordingly acknowledge and accept:
(a) that all urine samples taken will become the property of the UCI, which may have them analysed, especially for purposes of health protection research and information;
(b) that the results of any analysis may be made public and communicated in detail to my club or team or to my paramedical assistant or doctor;
(c) that my doctor or the doctor of my club or team may, on request from the UCI, communicate to the UCI a list of any medicines I took and treatment I underwent before any given competition;
(d) the conditions regarding blood testing and agree to undergo blood tests.
4. Warrant that the details set out in the Application for a Licence and Membership Form are true and correct. If they change I acknowledge that I am required to notify BikeNZ of the changes, in writing, as soon as possible after they occur.
5. Understand and agree that:
(a) BikeNZ and my Member Organisation may use the information collected in this form for purposes relating to my membership of BikeNZ and my Member Organisation and for communicating with me about my membership and matters affecting my Member Organisation and BikeNZ;
(b) The information will also be recorded on a BikeNZ database;
(c) BikeNZ and my Member Organisation may disclose the information to third parties, including sponsors, stakeholders, the UCI and other organisations referred to in this form;
(d) I will have access to my personal information; and my personal information will be corrected on request.
6. Acknowledge and agree that, where I participate in an event organised by BikeNZ, a Member Organisation or a club affiliated to a Member Organisation:
(a) I am aware of the dangers of road racing and the real risk of injury and accept all risks flowing from my participation in every event;
(b) I am responsible for reading and understanding any written race instructions;
(c) I will abide by all race rules and directions issued by the event organisers and will obey all relevant road rules;
(d) Briefings, signage, and course marshals, are a service to me and other competitors but are not a guarantee of safety;
(e) Should circumstances require a change of format or categories within an event, I consent to those changes being made by the organisers;
(f) As the organisers cannot control every eventuality, I release all persons associated with every event from any claims arising out of my participation;
(g) If I am involved in an accident, I will not seek to blame or make a claim against the organisers; nor will I assist anyone else in making such a claim;
(h) In the event of an accident I consent to receiving any medical treatment the event organiser or medical or paramedical personnel think necessary;
(i) I am responsible for the roadworthiness and safety of my bicycle and the security of all other equipment and personal possessions used in connection with every event;
(j) If I have any concerns with the race organisation, I will raise them with the organisers first.
Signature ……………………………………………………. Date …………………………………………………………………
Under 18yrs, parent, guardian, caregiver to consent
I am the parent/guardian/caregiver of the applicant who is under 18 years of age. I have read and understood the application for licence and membership form and the applicant’s declaration. I have explained the effect of this form to the applicant. I understand the form and the declaration and consent to the applicant’s application for a licence and membership on the basis set out in the form and declaration.
Surname ……………………………Given name ………………………….. Signature …………………………… Date ………………………..
PAYMENT DETAILS TO BIKENZ
Licence Fee / $ ______Insurance Fee
(International licences only) / $ ______
TOTAL AMOUNT / $ ______