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Membership Form & Payment

£20.00

Your Details *

Medical Information *

Please answer all 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 this section. This should include the date you first developed the condition, details of any tests, investigations and of any treatment you have undergone. Please include the names and addresses of any specialists you have send and hospitals you have attended. Please give full details of any medication you are taking.
Have you ever suffered from or are you currently suffering from any of the following illnesses or conditions?

Epilepsy, fits, blackouts or any condition which may cause loss of consciousness?

1) Any condition that might cause dizziness, vertigo or loss of balance? *

2) Have you been unconscious because of a head injury or suffered from concussion? *

3) Any brain disorder such as a stroke, MS or Motor Neurone disease? *

4) Any loss of strength, feeling, control or movement of any of your limbs, head or neck? *

5) Amputation of any part of your limbs with or without an artificial replacement? *

6) Any condition or operation involving your heart or main blood vessels or any high blood pressure? *

7) Any kind of tumour or cancer? *

8) Diabetes? If YES please state whether treated by diet, tablets or insulin. *

9) Any psychiatric or emotional illness or any alcohol/drug/substance misuse? *

10) Any condition affecting your vision or eyes, including colour blindness? *

11) Are you taking any medication? *

(Include all tablets, medicines etce., whether prescribed or bought over the counter.)

MOTOR SPORTS CAN BE DANGEROUS AND MAY INVOLVE INJURY OR DEATH *

Read carefully before signup to ensure you agree.

1. The answers given by me in this membership application are true.

2. I fully understand the type of the events which the membership allows me to enter and the rules and regulations that apply to such events and to competitors and will comply with them.

3. 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.

4. 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).

5. I will NOT enter or take part in any competition where I have a doubt as to my safety.

6. I will tell you immediately if, for any reason, I believe that I am no longer able to satisfy the terms of this member ship or I become aware that I have become unable to compete due to physical or other disability.

7. 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.

8. If under the age of 18, my parent/guardian has read the above and signed the declaration and agreement below:
I confirm that I have read the Codes of Practice and Regulations for the MC Federation and the Event Regulations and I agree to be bound by them in every respect. That I am fit and not suffering from any physical or mental disability which would impair my safe participation in the event. I undertake to inform NEMXC should any change in my condition occur which I have reason to or ought to have reason to believe would affect my ability to participate in this competition. That I have completed a medical questionnaire and that I will inform NEMXC should my medical status have changed. As a participant I may be exposed to the risk inherent in motor sport and that I am prepared to take such risks.

I further agree that I shall not seek to claim against MC Federation, NEMXC, their officials, the landowners, the promoter or other bodies or individuals connected with the event(s) in respect of any damage to my property howsoever caused, and whether by negligence or breach of statutory duty of the said bodies or persons.

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