Motorsport Licensing & Event Insurance - Club Racing Licence Application

Licence Venue Details

At which venue will you be using this licence for your first event?

Venue*

Please enter venue*

Personal Details

First Name*

Last Name*

Mobile*

Occupation*

Email*

Address (Postal Address)*

As this information is used for mail merging posted items, please ensure your address is entered with the correct casing. eg. 1 Main Street.

Address (Address Line 2)

City*

State*

Postcode*

Country*

Age*

Country of Birth*

Date of Birth*

IMPORTANT: AASA Club Racing Licence applications for 14-17 year old’s cannot be submitted online. Please complete the application form found here and submit it directly to the AASA office.

Are you an Australian citizen*

Yes
No

Gender*

Male
Female

Have you previously held a Motor Racing Licence?*

Yes
No

If yes, last year held?*

Previous Licence No.*

Issuing Body

Medical Information

Blood group*

Tetanus Immunisation Date

Allergies?

Yes
No

Please list*

Have you ever been diagnosed as having and/or had treatment for: (Please tick)

1. A psychiatric or psychological illness?*

Yes
No

2. Persistent or severe headache, head injury, epilepsy, seizure or loss of consciousness?*

Yes
No

3. Heart or lung disease, including infection, blood vessel disease, hypertension, coronary bypass, angioplasty or other surgical procedure?*

Yes
No

4. Cancer, diabetes, kidney, liver, thyroid, gastrointestinal, blood pressure disorders, including any associated surgical procedures?*

Yes
No

5. Any other significant illness, injury or surgery not already noted?*

Yes
No

6. Have you taken any medications, including self-medication or alternative therapies?*

Yes
No

7. Do you have any hearing impairment or loss?*

Yes
No

8. Do you suffer from any hearing disorder including tinnitus?*

Yes
No

9. Is your eyesight normal in both eyes for distance vision?*

Yes
No

If NO do you wear spectacles or contact lens?*

Yes
No

10. When did you last have a medical examination?*

Please give full details if you answered YES to any of the above questions:*

Personal Accident Weekly Benefit

The Flexible Insurance Options product overview can be found at the link below.
Please ensure that you have read this document thoroughly before apply for this additional cover.

FLEXIBLE INSURANCE OPTIONS OVERVEW →

Would you like to increase your personal accident weekly benefit provided under an AASA permit in the event of a claim?*

Yes
No

The standard benefit provided is $900 per week. Please refer to the online insurance summary for additional details. This cover only applies for claims which occur at an AASA sanctioned event.

Please select the amount you would like this increased to:*

$1,100 per week (cost is $500)
$1,300 per week (cost is $750)
$1,500 per week (cost is $1,000)

Benefit Overview Declaration*

I declare that I have read the Flexible Insurance Options overview and fully understand all aspects of this insurance product

Increase weekly benefits to $1,100*

Price: $ 500.00

Increase weekly benefits to $1,300*

Price: $ 750.00

Increase weekly benefits to $1,500*

Price: $ 1,000.00

Disclaimers & Payment

Declaration:
1/ I certify that the statements made regarding my psychological and physical condition and any previous illness are true and accurate.
2/ I understand that I will not use any drug considered illegal.
3/ I authorize any hospital or medical practitioner to furnish information relevant to my medical condition to a Medical Assessor in order to determine competition fitness.
4/ I acknowledge that motorsport is dangerous and agree that AASA shall not be under any liability whatsoever for any death or bodily injury, loss or damage which I may incur, howsoever such death or bodily injury, loss or damage is caused, by negligence or otherwise.

For Female Applicants: I agree to refrain from participating in any motor sport events except touring events if I am aware that I am or may be pregnant, and to abide by AASA’s HSE policy regulations.

Female Driver Acknowledgement*

I AGREE THAT AS A FEMALE I HAVE READ AND UNDERSTAND THE ABOVE STATEMENT

Club Racing Licence Fee*

Price: $ 85.00

Coupon

Total

$ 0.00

Declaration*

I declare that all information provided for the purposes of this application is true and accurate to the best of my knowledge. I understand that in providing false or misleading information my licence may be suspended or cancelled, and I may not be afforded the coverage of the Personal Accident and Injury insurance provided under the AASA Insurance Scheme. I agree to comply with the AASA National Competition Rules at all times when participating in a AASA Sanctioned Event.

Credit Card*

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name