APPLICATION FOR ONE DAY ADULT COMPETITION LICENCE

APPLICATION FOR ONE DAY ADULT COMPETITION LICENCE

FULL NAME: ………………………………………….......……...................................................

ADDRESS: ……………………………………………………………………………………………

………………………………………………………………      POST CODE ……………………

DATE OF BIRTH: ………………………………………...      MALE/FEMALE* delete as appropriate

I wish to purchase a one event adult competition license for the following event:

Event: Anglesey Circuit                                  Date of Event: …………………………..

Organising Club:  Anglesey Car Club Circuit Racing

Venue: Anglesey Circuit, Aberffraw, Anglesey.

Medical Declaration

1.      Have you been rejected, or accepted at increased premiums for life insurance on medical grounds?  

                                                                                                                                                            YES/NO*

2.       Have you been treated for, do you now have, or have you ever had any of the following:
(a) Head injury?                                                                                                 YES/NO*
(b) Unconsciousness or concussion (within the last 28 days)?                                  YES/NO*
(c) High blood pressure/heart disease or disorder?                                                 YES/NO*
(d) Dizziness, fainting spells, epilepsy, fits or blackouts?                                          YES/NO*
(e) Disease, injury or operation to either eye?                                                        YES/NO*
(f) Do you have any vision defect or loss of sight in either eye?                                YES/NO*
(g) Do you have any condition which affects movement of arms or legs?                   YES/NO*
(h) Do you have any false or missing limbs?                                                           YES/NO*

* If you have answered YES to any of the above, please give further details:
…………………………………………………………………………………………………………………………………………

I certify that the above statements are true and accurate and I understand 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invalid/withdrawn should any prove to be so.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 my medical condition to ORPA.

Signature: …………………………………………….  Date: ……………………………………..

Signature of Parent/Guardian: …………………………..…………(if under 18 years of age)