Motorsport Licensing & Event Insurance - Karting Day Licence Application

Event Details

Event Name*

Event Duration*

Single Day
Multi Day (Max 2 days)

Single Day Event Date*

Multi Day Event Start Date*

Multi Day Event End Date*

Please ensure the dates entered are consecutive dates. Applications containing non consecutive dates will not be valid.

Personal Details

First Name*

Last Name*

Mobile*

Occupation*

Email*

Address (Street 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 Day Licence applications for 14-17 year old’s cannot be submitted online. Please contact the AASA office on 03 5721 7800.

Are you an Australian citizen*

Yes
No

Gender*

Male
Female

Have you previously held a Kart 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:*

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.

Famale Driver Acknowledgement*

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

Competency Declaration by Club/ Organization or Individual.
This applicant is recommended by Club/ Organization/ Individual who is personally known to AASA

Name of Club/ Organization/ Individual:

Karting - Single Day Event Day Licence*

Price: $ 35.00

Karting - Multi Day Event Day Licence*

Price: $ 70.00

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

PLEASE NOTE: If you are under 18, please contact AASA on 03 5721 7800.

Please complete the online application below.

Event Details

Personal Details

Medical Information

Disclaimers & Payment