Stopastride Live | HILLCLIMB 28/29 JUNE Entry Form

Driver

Forename*

Surname*

Address*

Town/City*

Postcode*

Email*

Telephone*

Competition Licence Number*

Issuing Association*

eg. Motorport UK/Ireland

Licence Type*

eg. RS Clubman

Next of Kin:

Name*

Relationship*

Telephone*

Driver over age of 18*

Yes

Date of Birth*

Driver's Parent/Guardian/Guarantor:

Name*

Telephone*

Address*

Full address including postcode, or 'as above' if same as driver's address.

Car

Make*

Model*

Cubic Capacity*

* IMPORTANT – COMPETITORS UNDER 18
Competitors under 18 years of age (Minor) must be entered in the event by the holder of a Minor Entrant Licence who must countersign this entry form. A Minor Entrant who is not the parent/legal guardian of the Minor, must be Garda Vetted. Where an adult sits in the same car as a Minor competitor, the adult must be the holder of a Minor Entrant Licence, if they are not the Minor’s Parent/Legal Guardian this licence must include Garda Vetting. It is not permitted to have two minors in the same vehicle.

If the car has a competition number displayed, please state the number

Number displayed (both sides)

Dual Entry

Dual Entry?

Yes

Full name of other driver*

All drivers must submit a separate entry form

Entry Fee's

	Cost	Select
Junior 1 day (SATURDAY)	€150
Junior 1 day (SUNDAY)	€150
Junior 2 day	€250
Main Field 2 day	€320
Main Field 1 day (SATURDAY)	€200
Main Field 1 day (SUNDAY)	€200

Total: €0

Payment Method*

Credit/Debit Card

I have read, understand and accept Westmeath Motor Club's privacy policy and Stopastride Live Timing's privacy policy. *