The Midland Rover Owners Club Soap Box Derby

JUNIOR ENTRY FORM

TEAM NAME. ============================================================== ========== CONTACT NAME & ADDRESS. ======================================================================== ======================================================================== TEL NO ================================ EMAIL ===========================

JUNIORS OVER 12 & UNDER 16 ENTRY FEE 2

The rules & regulations of this event are for the benefit & safety of the competitors & spectators & must be strictly adhered to. The organisers of this event The Midland Rover Owners Club will make Health & Safety at this and all its events a priority. However no responsibility for any damage, loss , or injury to the entrants or to the entrants Soap Box & equipment will be accepted by the organisers. WE the undersigned, enter & allow entry to this event having read, & understood & agreed to the rules & regulations of this event. We will accept full responsibility for any damage to our person or soapbox & equipment. ENTRIES MUST BE RECEIVED NO LATER THAN 1ST JULY 2012 PLEASE SEND COMPLETED FORM & CHEQUE FOR 2-00 MADE OUT TO THE MIDLAND ROVER OWNERS CLUB To: M.Boyle, 29 Dorncliffe Avenue, Sheldon, Birmingham, B33 0PH

TEAM MEMBERS PRINT NAME

TEAM MEMBERS SIGNATURES

DATE OF BIRTH

PARENT GUARDIAN NAME

PARENT GUARDIAN SIGNATURE