Have you been rejected, or accepted at increased premiums for life insurance on medical grounds?
YesNo
Have you been treated for, do you now have, or have you ever had any of the following:
Head Injury?
YesNo
Unconsciousness or concussion?
YesNo
High blood pressure/heart disease or disorder
YesNo
Dizziness, fainting spells, epilepsy, fits or blackouts?
YesNo
Disease, injury or operation to either eye?
YesNo
Do you have any vision defect or loss of sight in either eye?
YesNo
Do you have any condition which affects movement of arms or legs?
YesNo
Do you have any false or missing limbs?
YesNo
If you have answered YES to any of the above statements, please give further details:
RIDER 2 DETAILS:
Forename:
Surname:
Address:
Postcode:
Date of Birth:
Day Month Year
Sex:
Male
Female
Contact Numbers:
Home
Mobile
Email:
Bike details:
Make
Model
Year of Manufacture
Previous Years Entered:
2002
2003
2004
2005
2006
2007
2008
2009
None
MEDICAL DECLARATION:
Have you been rejected, or accepted at increased premiums for life insurance on medical grounds?
YesNo
Have you been treated for, do you now have, or have you ever had any of the following:
Head Injury?
YesNo
Unconsciousness or concussion?
YesNo
High blood pressure/heart disease or disorder
YesNo
Dizziness, fainting spells, epilepsy, fits or blackouts?
YesNo
Disease, injury or operation to either eye?
YesNo
Do you have any vision defect or loss of sight in either eye?
YesNo
Do you have any condition which affects movement of arms or legs?
YesNo
Do you have any false or missing limbs?
YesNo
If you have answered YES to any of the above statements, please give further details:
RIDER 3 DETAILS:
Forename:
Surname:
Address:
Postcode:
Date of Birth:
Day Month Year
Sex:
Male
Female
Contact Numbers:
Home
Mobile
Email:
Bike details:
Make
Model
Year of Manufacture
Previous Years Entered:
2002
2003
2004
2005
2006
2007
2008
2009
None
MEDICAL DECLARATION:
Have you been rejected, or accepted at increased premiums for life insurance on medical grounds?
YesNo
Have you been treated for, do you now have, or have you ever had any of the following:
Head Injury?
YesNo
Unconsciousness or concussion?
YesNo
High blood pressure/heart disease or disorder
YesNo
Dizziness, fainting spells, epilepsy, fits or blackouts?
YesNo
Disease, injury or operation to either eye?
YesNo
Do you have any vision defect or loss of sight in either eye?
YesNo
Do you have any condition which affects movement of arms or legs?
YesNo
Do you have any false or missing limbs?
YesNo
If you have answered YES to any of the above statements, please give further details:
EACH ENTRANT MUST READ, AND AGREE TO THE FOLLOWING DECLARATION :
(If Entrant is under 18 years of age, then a Parents name MUST be entered below and NOT the Entrants name)
I certify that the above statements are true and accurate and I understand that my license may be invalid/withdrawn should any prove to be so. I also authorise any hospital or medical practitioner to furnish information relative to me medical condition to ORPA.
I hereby declare that I have read and understand the rule book of the ORPA and agreed to be bound by them together with the supplementary regulations as have or may be issued for the event. I further declare that I am physically and mentally fit to take part in the event and am competent to do so. I confirm that I understand the nature and type of the event and the risks inherent with the sport and agree to accept the same not withstanding such risks may involve negligence on the part of the organization and / or officials. I further agree that I shall not seek to claim against the ORPA, the organizers and / or officials, the land owner, the promoter or other bodies or individuals connected with the event in respect of any damage to my property howsoever caused and whether by the negligence or breach of statutory duty of the said bodies and persons. I further agree that the machine, which I enter and race, shall be suitable and proper for its purpose and that it will comply with the regulations in respect thereof. I understand and agree that I am required as soon as I arrive at the venue to register my arrival and sign on at any designated area.
I RIDER 1, the entrant agree to the terms listed above
Name of Parent or Guardian of RIDER 1 (if under 18 years of age):
I RIDER 2, the entrant agree to the terms listed above
Name of Parent or Guardian of RIDER 2 (if under 18 years of age):
I RIDER 3, the entrant agree to the terms listed above
Name of Parent or Guardian of RIDER 3 (if under 18 years of age):
