SOUTH EASTERN AUTOMOBILE CLUB OF SA INC

ENTRY FORM

KHANACROSS ROUND 2, 14th MARCH, 2010

PERMIT NUMBER  510/1403/01

HELD UNDER THE INTERNATIONAL SPORTING CODE OF THE FIA AND THE NATIONAL COMPETITION RULES OF CAMS.

MAKE & MODEL:

CLASS:

LOG BOOK NO: (IF APPLICABLE)

CAR NO.

COMPETITOR NAME:

CLUB:

MEMB NO:

DATE:

ADDRESS:

CAMS LIC NO:

PAID:

1ST DRIVER:

CAMS LIC NO:

MEMB NO:

DATE:

ADDRESS:

PHONE:

CLUB:

PAID:

2ND DRIVER:

CAMS LIC NO:

MEMB NO:

DATE:

ADDRESS:

PHONE:

CLUB:

PAID:

3RD DRIVER:

CAMS LIC NO:

MEMB NO:

DATE:

ADDRESS:

PHONE:

CLUB:

PAID:

4TH DRIVER:

CAMS LIC NO:

MEMB NO:

DATE:

ADDRESS:

PHONE:

CLUB:

PAID:

DISCLAIMER

EXCLUSION OF LIABILITY, RELEASE AND ASSUMPTION OF RISK COMPETITORS AND/OR DRIVERS

For competitors and drivers in all competitions. competitor is defined as the legal owner of the car

For Competitors

I/We being the competitor/s of the vehicle described on this Entry Form wish to enter that vehicle for the above event.

For Competitors and Drivers

I/We being the competitor/s and/or driver, certify that the particulars on this form are true and correct in every particular, to the best of my/our

knowledge and belief.

I/We declare that I/we have read and understood the Supplementary Regulations issued for the event, and agree to be bound by them and the provisions of

the National Competition Rules of the Confederation of Australian Motor Sport Limited (“CAMS”).

In exchange for being able to attend or participate in the event (including entering the event), I agree:

•  to release CAMS and Australian Motor Sport Commission Ltd, promoters, sponsor organisations, land owners and lessees, organisers of the event,

their respective servants, officials, representatives and agents (collectively, the "Associated Entities") from all liability for my death, personal injury

(including burns), psychological trauma, loss or damage (including property damage) ("harm") howsoever arising from my participation in or

attendance at the event, except to the extent prohibited by law;

•  that CAMS and the Associated Entities do not make any warranty, implied or express, that the event services will be provided with due care and skill

or that any materials provided in connection with the services will be fit for the purpose for which they are supplied; and

•  to attend or participate in the event at my own risk.

I/we acknowledge that:

•  the risks associated with attending or participating in the event include the risk that I may suffer harm as a result of:

•  motor vehicles (or parts of them) colliding with other motor vehicles, persons or property;

•  acts of violence and other harmful acts (whether intentional or inadvertent) committed by persons attending or participating in the event; and

•  the failure or unsuitability of facilities (including grand-stands, fences and guard rails) to ensure the safety of persons or property at the event.

•  motor sport is dangerous and that accidents causing harm can and do happen and may happen to me.

I accept the conditions of, and acknowledge the risks arising from, attending or participating in the event and being provided with the event services by

CAMS and the Associated Entities.

I understand that this disclaimer is not intended to exclude any valid claim I may have under the CAMS Personal Insurance Scheme.

Competitor's signature: ................................................…...

Date: ........................................

Driver/s signature:      .........................................................

Date: ........................................

.........................................................

.........................................................

For persons under the age of 18 years the following parent/guardian consent must be completed.

PARENT/ GUARDIAN CONSENT – PERSONS UNDER 18 YEARS OLD

I …………………………………… of  [Address] ………………………………………………… am the parent/ guardian* of the above-named ("the minor") who is

under 18 years old.  I have read this document and understand its contents, including the exclusion of liability and assumption of risk, and have

explained the contents to the minor.  I consent to the minor attending/ participating in* the event at his/her own risk.

Signed…………………………………………………

Date…………………………………………………

Parent/Guardian*

* Delete whichever does not apply