Western Province Motor Club

P.O. Box 220 Table View 7439, 6 Potsdam Road, Killarney Gardens
Tel:021 557 1639,Fax: 021 557 6904, e-mail: admin@wpmc.co.za

STREET MANIA ENTRY FORM 2022

I hereby apply to participate in the event to be held on the 2022. Amount Paid:
……………………….
Entry is only VALID once payment has been received by the WPMC!

GroupEntered
(Mark with X) STREET2STRIP DRIFTING SPINKHANA

DRIVER DETAILS
Full Name: ID. No.

e-mail: Cell:

Emergency Contact Emergency Tel.

Person:

TEAM MEMBER DETAILS

Crew 1 ID No. Contact
Full Names Number
Crew 2 ID No. Contact
Full Names Number

VEHICLE DETAILS
Vehicle Make Type / Model Year
Engine Make Naturally Yes / No Road legal Yes / No
Aspirated tyres

DECLARATION/UNDERTAKING TO BE SIGNED BY EVERY DRIVER:

I / We agree to obey the events officials instructions and agree to abide by the events Rules and Covid Regulations by signing this entry form.

Driver signature…………………………………………………..… Print………………………………………………………………...

Entry Fees BANKING DETAILS:

Driver: (non WPMC member) R300 including driver and two crew members Western Province Motor Club
Nedbank, Southern Peninsula
A/C 1232041807
Driver: (WPMC member) R230 including driver and two crew members B/C 123209

Notice in terms of the Protection of Personal Information Act:

Personal information is collected for a specific, explicitly defined and lawful purpose related to a function or activity of Western Province Motor Club.
The information will –
I. Not be used in a form in which the data subject may be identified; or
II. Not be used for historical, statistical or research purposes.
III. Not be sold or in any manner distributed to a third party for use in mailing lists

I hereby authorise WPMC to use my:

Email address Mobile number Tick applicable (one or both) For electronic communication from WPMC.
 WESTERN PROVINCE MOTOR CLUB
Tel: 021 5571639 VAT Reg. No. 4430103772
Fax: 021 5576904
Email: info@wpmc.co.za
Website: www.wpmc.co.za
WESTERN PROVINCE MOTOR CLUB - Waiver and Indemnity Document (Rev01)
I, the undersigned, do hereby state and agree that:
1. I am aware of the potential dangers involved in the
participation in motorsporting activities;
2. I am further aware that Western Province Motor Club
('the Club"), in organising and permitting my participation in
such activities and in establishing and enforcing safety
measures in regard thereto, cannot ensure my safety and/or
the adequacy of such measures. The Club for purposes of this
indemnity and waiver includes its sections and all subordinate
bodies, office-bearers, officials, employees and private
individuals conducting activities under the auspices of, or in
conjunction with, or utilising the facilities of, the Club as well
as the sponsors of events
3. As such, I undertake to:
(a) take all necessary safety precautions as I am aware of
the risk and involved in participating in motorsport activities;
(b) exonerate all persons and bodies involved in the
organisation and sponsorship of the motorsport and related
activities at Killarney and elsewhere under the auspices of
the Club, including Motorsport South Africa and its
subordinate bodies from, and indemnify them against, any
loss or damage, of whatsoever nature, which I or any
others, including my dependants may suffer due to any
act or omission on the part of such body or person and
which was beyond the reasonable control of the Western
Province Motor Club;
(c) comply with all applicable safety rules and
regulations of Motorsport South Africa and its subordinate
bodies, club rules or regulations, and/or the direction of any
official in charge of any such activity;
(d) I acknowledge that in the event of my utilising
any track or other facility of the Club, outside of official
competition or practice, that all of the safety precautions
normally in place may not be present, and that the
circuits, tracks and other facilities, and in particular the
safety installations relating thereto, may be in the course
of modification or repair, or may have been moved. It will
therefore be my duty to satisfy myself that the circuit or
track can be safely utilised and to adjust my driving or
riding to take into account the prevailing circumstances
at the time.
I (Full Names)…………………………………………………………………………………………………………………………........……….
hereby acknowledge the abovementioned agreement, the contents of which are fully understood and accepted by me.
SIGNED AT……………………….………… THIS......................... DAY OF………………………………….. 2022
Emergency contact name...........................................................Emergency contact number...........................................................
Signature _____________________________
Minors (under 18 and never married):
I (Full Names)……………………………………………………………………………………………………………………………………..… ,in
my capacity as parent/guardian/curator hereby acknowledge the abovementioned agreement, the contents of which are fully
understood and accepted by me and by my son/daughter/ward.
SIGNED AT……………………….………… THIS......................... DAY OF………………………………….. 2022
Signature _____________________________
P.O. Box 220, Table View, 7439
6 Potsdam Road, Killarney Gardens
Cape Town
(e) I acknowledge that it will be my further duty to keep my
dependants appraised of my participation and to ensure that they
are aware of this waiver and indemnity.
4. I hereby waive, for myself and my dependants any
claim which I may have against Western Province Motor Club
and all persons and bodies involved in the organisation and
sponsorship of the motorsport and related activities at Killarney
and elsewhere under the auspices of the Club, including
Motorsport South Africa and its subordinate bodies from, any
loss or damage which I may suffer as a result of any injury or
death as a result of any act or omission on the part of such body
or person which was beyond their reasonable control;
5. I indemnify Western Province Motor Club and all
persons and bodies involved in the organisation and
sponsorship of the motorsport and related activities at
Killarney and elsewhere under the auspices of the Club,
including Motorsport South Africa and its subordinate bodies
against any claim by any of my dependants for any
damage or loss which they may suffer as a result of any
injury or death as a result of any act or omission on the part
of such body or person, which was beyond their reasonable
control. It is my intention that this indemnity will be binding
upon my estate.
6. I undertake in favour of Western Province Motor Club,
that I will not in any way facilitate the use by any person of the
sporting facilities of the club unless such person has signed a
similar waiver and indemnity in favour of the club. In particular,
and without limiting the generality of the aforegoing, I undertake
not to allow the use of any vehicle, (including for this purpose,
karts, motorcycles, quad bikes and other forms of motorised
transport,) owned or under my control by any such person or to
permit any such person to be a passenger in such vehicle while
using any of the sporting facilities of the club. To the extent that I
may breach the undertaking given in this paragraph I indemnify
the club on the same basis set forth in five above against any
claim by any such person or his or her dependants.