1. society
2. sex

National & International Licence Application/Renewal 2015
Licence Levels:
Circuit Licences (inc historic):
PCC, CC, PC, NC, ICA, ICB, ICC, ICD, CH
Off Road Licences:
NOJ, NO, NON, NONJ, NOS
Rally Licences:
NRNJ, NRJ, CRN, CR, NRN, NR, IRN, IR
Superkart Licences:
PSKJ, PSK, NSKJ, NSK, ISK
Received Stamp Here
CAMS Member Number:
(office use only)
(All licences are VALID for Level 2 activity)
Type of licence applied for:
Your Fixed Expiry Date:
Next Medical Due:
Personal Details
Surname:
Given names:
Australian postal address:
Town/Suburb:
Post Code:
State:
Mobile:
Home:
Fax:
Email:
Please attach
a passport
size photo
here
Date of birth:
Gender:
Female
Male
Emergency contact
name (1):
(if not previously
supplied)
Telephone:
Emergency contact
name (2):
Telephone:
Do you have an
Australian citizenship or
permanent residency?
Yes
No
If ‘No’ nationality of passport
If No, you are required to provide documentary evidence of your Australian Status. This can include: Appropriate section of your
passport, utility bill showing your residential address or a statutory declaration indicating that you are a resident of Australia.
Office Use Only
CAMS Member Number:
Receipt No:
www.cams.com.au
Date:
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Amount:$
1300 883 959
CAMS-Affiliated Club Membership
Please list the CAMS-Affiliated club(s) of which you are a member (no abbreviations):
Note: it is compulsory for all CAMS driver licence holders to be a member of a CAMS-affiliated “sporting” car club.
Full name of club (1):
State:
Full name of club (2):
State:
Licence Selection
PLEASE NOTE, A $10 AIMSS CONTRIBUTION IS INCLUDED IN ADULT LICENCE FEES.
Circuit
Rally
ICA International Circuit A (18)
$ 1,792
IR International Rally (16)
$ 469
ICB International Circuit B (18)
$ 1,689
IRN International Rally Navigator (16)
$ 469
ICC International Circuit C (16)
$ 1,576
NR National Rally (16)
$ 237
ICD International Circuit D (16)
$ 1,420
NRN National Rally Navigator (16)
$ 237
NC National Circuit (16)
$ 474
PC Provisional Circuit (16)
$ 474
CR Clubman Rally (16)
$ 175
CC Clubman Circuit (16)
$ 299
CRN Clubman Rally Navigator (16)
$ 175
PCC Provisional Clubman Circuit (16)
$ 299
NRJ National Rally Junior (14)
$ 55
NRNJ National Rally Junior Navigator (14)
$ 55
Historic
$ 536
CH International Circuit C Historic (previously H1)
Off Road
NO National Off Road (16)
Superkart
$ 222
NOJ National Off Road Junior (14)
$ 55
ISK International Superkart (16)
$ 809
NON National Off Road Navigator (16)
NSK National Superkart (16)
$ 371
NONJ National Off Road Navigator Junior (12)
$ 222
NSKJ National Superkart Junior (12)
$ 135
PSK Provisional Superkart (16)
$ 371
PSKJ Provisional Superkart Junior (12)
$ 135
$ 55
If you have selected more than one licence
type please write the most expensive amount $
here
OPTIONS
Urgent Fee - $70:
Required if the licence is needed within 5
working days of application being received
by CAMS.
CAMS Manual:
The CAMS manual is available at
www.cams.com.au. If you require a printed
copy, select this option.
CAMS Official:
Select this option if you would like to
register to become a CAMS Official.
(there is no cost to become a CAMS
Official and to get started you just need to
complete an Online Module)
AIMSS Contribution:
The Australian Institute of Motor Sport Safety is a national not for profit organisation founded by
CAMS which is committed to improving safety in motor sport at all levels in Australia. Visit aimss.
com.au for further information. IF YOU DO NOT WISH TO MAKE A $10.00 CONTRIBUTION
TO THE WORK OF THIS IMPORTANT ORGANISATION, PLEASE TICK THE BOX. (Levy not
applicable to Junior Licences).
Passbook:
Select this option if you require a new
competitor pass book.
Grand Total:
$
Grand Total should reflect the total of licence fee and options selected.
Payment
Paying By (please tick appropriate box):
Cash (ONLY if paying in person at a CAMS Office:
Cheque (made payable to “Confederation of Australian Motor Sport Limited”:
Money Order (made payable to “Confederation of Australian Motor Sport Limited”:
Credit Card (please complete details below):
Card Type:
Master Card:
Visa:
Card Number:
Name on Card:
www.cams.com.au
Expiry Date:
Signature:
SIGN HERE
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New Licence Conditions
PRE LICENCE LECTURE
All new licence applicants are required to complete an online lecture on the requirements of the CAMS Manual of
Motorsport and procedures involved in their particular discipline.
N.B. If you have completed a valid Pre Licence Lecture in the last 24 months for the relevant discipline, you are not required
to repeat this lecture.
CAMS Member Services will automatically enrol you in this course upon receipt of your application. Login details and
guidelines will be sent to your nominated email account.
I acknowledge that I am required to undertake an online lecture as a condition of receiving this licence.
OBSERVED LICENCE TEST
Are you :
•
•
•
•
•
Under the age of 25 years?
Applying for a new licence in the following disciplines: Superkart; Off-Road; Off-Road Stadium?
Over the age of 25 years, applying for a Rally licence and not held a civil road licence for over 5 years?
Applying for a Provisional Circuit or Provisional Clubman Circuit Licence and have NOT :•
Competed in 5 CAMS Multi-Car Sprint (supersprint) or Regularity events within the last 24 months; OR
•
Competed in 2 CAMS Tarmac Rally events within the last 24 months; OR
•
Held a CAMS PCC/PC/PSK/NSK in the last four years.
Applying for a National Circuit or Clubman Circuit Licence and have NOT :•
Held an AKA B-Grade licence (or higher) OR a CAMS NSK/ISK licence; OR
•
Previously held a CAMS NC (or higher) licence in the last 4 years.
N.B. Evidence of competition history must be submitted with this application
If you meet any of the previous criteria, you will need to complete an Observed Licence Test.
An Observed Licence Test is where your driving style, ability and attitude are evaluated in simulated race conditions. Upon
receipt of your application, CAMS will issue you with a Pre-Licence Authority (PLA) form which you will need to take with
you along to your Observed Licence Test. The cost and process varies from State to State.
Please contact CAMS on 1300 883 959 for assistance in booking your Observed Licence Test.
I acknowledge that I am required to complete an Observed Licence Test prior to receiving my licence.
For further information regarding Observed Licence Tests, please refer to the Licence Section in the CAMS Manual of Motor
Sport, which can be found online at www.cams.com.au.
Renewal Conditions
INTERNATIONAL LICENCES
• For International A and B licences you must have been observed in one (1) International Circuit event in the last 12 months.
• For International C and D Circuit Racing you must have participated or been observed in one (1) International Circuit event or two (2)
CAMS Circuit Events in the last 24 months.
• For International Rally you must have competed in at least one (1) International or two (2) CAMS Rally events in the last two years.
NATIONAL LICENCES
• For Circuit, Rally and Off-Road Racing (CC, PCC, PC, NC, CR, CRN, NRN, NR, NON, NO) you must have competed in at least one
CAMS permitted event in the past 4 years for each discipline.
•For Superkart Racing (PSK, NSK) you must have competed in at least one CAMS permitted Superkart event in the past 2 years.
I have met the renewal conditions specific to my licence type
www.cams.com.au
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Fit and Proper Person
I acknowledge and agree that it is a fundamental condition of issue of this licence and its continuing validity that I:
•have advised CAMS in writing of any act, omission, fact or circumstance which may affect my ability to be and remain a fit and
proper person to hold this licence and exercise the duties and privileges that relate to it;
•have advised CAMS in writing if I have been found guilty of or charged with any serious or indictable criminal offence or of or with
any sexual offence (unless this is a ‘spent’ or ‘annulled’1 conviction); and
•undertake to advise CAMS immediately in writing upon any court of competent jurisdiction making any such finding, or upon being
charged with any such offence.
I acknowledge and agree that CAMS may, in its absolute discretion, cancel, suspend or withdraw this licence at any time should
it form the view that I may not be or am not a fit and proper person to hold this licence and/or exercise any of the duties and/or
privileges that relate to it, without ascribing any reason or holding any hearing.
1 As determined by the Crimes Act 1914 (Cth), Criminal Records Act 1991 (NSW), Criminal Law (Rehabilitation of Offenders) Act 1986 (Qld), Spent Convictions Act 2000
(ACT), Criminal Records (Spent Convictions) Act 1992 (NT), Spent Convictions Act 1988 (WA) and/or the Annulled Convictions Act 2003 (Tas) (including their successors and
replacements.)
Medical Assessment Requirements
Are you :
Applying for a new or renewed International Licence?
Applying for a new Circuit, Historic, Superkart or Off-Road Stadium Licence?
Age 45 or over and applying for a new or renewed Circuit, Historic, Superkart or Off-Road Stadium Licence?
N.B. Applicants over 45 years of age are required to undergo a Medical Examination every second year only.
Health Statement
Please tick if you have any significant or recurrent problems with the following:
Anxiety/depression or other mental health condition
Heart disease
Diabetes
Do you suffer from any allergies?
Epilepsy
Hearing loss or deafness
Fits/fainting/dizziness
Do you wear glasses or contact lenses when driving?
Headaches/migraine/head injury
If you ticked any of the above you must submit a Medical Report to CAMS filled in by your General Practitioner or Specialist.
Is there any other relevant medical information that you wish to advise us of?
I hereby declare the above provided information is correct.
If you have ticked any of the above boxes or informed us of any other medical information, please see CAMS’ Medical Fitness policy
available at CAMS’ website (www.cams.com.au). CAMS may request further information from you or your doctor before accepting your
application for a licence. Depending on your medical history or status, CAMS may not be able to issue you with a licence.
www.cams.com.au
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Risk Warning and Disclaimer
RISK WARNING AND ASSUMPTION OF RISK
Motor Sport Activities are inherently dangerous recreational activities and there is significant risk of injury, disability or death.
If you do not wish to be exposed to such risks, then you should not participate in the Motor Sport Activities.
I acknowledge that:
•the risks associated with attending or participating in Motor Sport Activities include but are NOT LIMITED to the risk that I may suffer harm as a result of:
• motor vehicles (or parts of them) colliding with other motor vehicles or persons or property;
• others participants acting dangerously or with lack of skills;
• high levels of noise exposure;
• acts of violence and other harmful acts (whether intentional or inadvertent) committed by persons attending or participating in the event; and
• the failure or unsuitability of facilities (including grand-stands, fences and guard rails) to ensure my safety.
EXCLUSION OF LIABILITY, RELEASE & INDEMNITY
In exchange for being able to attend or participate in the Motor Sport Activities, I agree:
•to release CAMS and the Entities to the extent that any or all of them are providing Recreational Services from all liability for:
• my death;
• any physical or mental injury (including the aggravation, acceleration or recurrence of such an injury);
• the contraction, aggravation or acceleration of a disease;
• the coming into existence, the aggravation, acceleration or recurrence of any other condition, circumstance, occurrence, activity, form of behaviour, course of conduct or
state of affairs:
• that is or may be harmful or disadvantageous to me or the community; or
• that may result in harm or disadvantage to me or the community,
howsoever arising from my participation in or attendance at the Motor Sport Activities;
•to indemnify and hold harmless and keep indemnified CAMS and the Entities to the maximum extent permitted by law in respect of any Claim by any person; and
•to attend at or participate in the Motor Sport Activities at my own risk.
I understand that:
•nothing in this document excludes, restricts or modifies any rights that I may have as a result of significant personal injury that is caused by the Reckless Conduct of CAMS and the
Entities as the supplier of the Motor Sport Activities / Recreational Services;
•nothing in this document prevents the Entities from relying on any laws (including statute and common law) that limit or preclude their liability;
•nothing in this document excludes any term or guarantee which under statute cannot be excluded; however the liability of the Entities is limited to the minimum liability allowable
by law;
•nothing in this document precludes me from making a claim under a CAMS insurance policy where I am expressly entitled to make a claim under that insurance policy; and
•CAMS has arranged some limited personal injury insurance coverage which may provide me with some protection for loss, damage or injury that I may suffer during my participation
in the Motor Sport Activities. However, I acknowledge and accept that the insurance taken out by CAMS may not provide me with full indemnity for loss, damage or injury that I
may suffer during my participation in the Motor Sport Activities, and that I may have to pay the excess if a Claim is made under an insurance policy on my behalf. I agree that my
own insurance arrangements are ultimately my responsibility and I will arrange any additional coverage at my expense after taking into account CAMS insurance arrangements, this
document and my own circumstances.
Where Motor Sport Activities are held in the following jurisdictions, I acknowledge that I have also read and accept the following warnings:
WARNING APPLICABLE IN RELATION TO MOTOR SPORT ACTIVITIES HELD IN VICTORIA
WARNING UNDER THE AUSTRALIAN CONSUMER LAW AND FAIR TRADING ACT 2012:
Under the Australian Consumer Law (Victoria), several statutory guarantees apply to the supply of certain goods and services. These guarantees mean that the supplier named on this
form is required to ensure that the recreational services it supplies to you:
•are rendered with due care and skill;
•are reasonably fit for any purpose which you either expressly or by implication, make known to the supplier; and
•might reasonably be expected to achieve any result you have made known to the supplier.
Under section 22 of the Australian Consumer Law and Fair Trading Act 2012 (Vic), the supplier is entitled to ask you to agree that these conditions do not apply to you. If you sign this
form, you will be agreeing that your rights to sue the supplier under the Australian Consumer Law and Fair Trading Act 2012 if you are killed or injured because the services were not
in accordance with these guarantees, are excluded, restricted or modified in the way set out in this form.
NOTE: The change to your rights, as set out in this form, does not apply if your death or injury is due to gross negligence on the supplier’s part. “Gross negligence” in relation to an act
or omission, means doing the act or omitting to do an act with reckless disregard, with or without consciousness, for the consequences of the act or omission. See regulation 5 of the
Australian Consumer Law and Fair Trading Regulations 2012 and section 22(3)(b) of the Australian Consumer Law and Fair Trading Act 2012.
WARNING APPLICABLE IN RELATION TO MOTOR SPORT ACTIVITIES HELD IN SOUTH AUSTRALIA
Your rights:
Under sections 60 and 61 of the Australian Consumer Law (SA), if a person in trade or commerce supplies you with services including recreational services), there is:
•a statutory guarantee that those services will be rendered with due care and skill;
•a statutory guarantee that those services, and any product resulting from those services, will be reasonably fit for the purpose for which the services are being acquired (as long as
that purpose is made known to the supplier); and
•a statutory guarantee that those services, and any product resulting from those services, will be of such a nature, and quality, state or condition, that they might reasonably be
expected to achieve the result that the consumer wishes to achieve (as long as that wish is made known to the supplier or a person with whom negotiations have been conducted
in relation to the acquisition of the services.
Excluding, Restricting or Modifying Your Rights:
Under section 42 of the Fair Trading Act 1987 (SA), the supplier of recreational services is entitled to ask you to agree to exclude, restrict or modify his or her liability for any personal injury
suffered by you or another person for whom or on whose behalf you are acquiring the services (a third party consumer). If you sign this form, you will be agreeing to exclude, restrict or
modify the supplier’s liability with the result that compensation may not be payable if you or the third party consumer suffer personal injury.
Important:
You do not have to agree to exclude, restrict or modify your rights by signing this form. The supplier may refuse to provide you with the services if you do not agree to exclude, restrict or
modify your rights by signing this form. Even if you sign this form, you may still have further legal rights against the supplier. A child under the age of 18 cannot legally agree to exclude,
restrict or modify his or her rights. A parent or guardian of a child who acquires recreational services for the child cannot legally agree to exclude, restrict or modify the child’s rights.
Agreement to exclude, restrict or modify your rights:
I agree that the liability of the CAMS and Entities for any personal injury that may result from the supply of the recreational services that may be suffered by me (or a person for whom or
on whose behalf I am acquiring the services is excluded.
Further information about your rights can be found at www.ocba.sa.gov.au
DEFINITIONS
a. “CAMS” means the Confederation of Australia Motor Sport Ltd.
b. “Claim” means and includes any action, suit, proceeding, claim, demand or cause of action however arising including but not limited to negligence, BUT does NOT include a claim
under a CAMS insurance policy by any person expressly entitled to make a claim under that insurance policy;
c. “Entities” means event and competition organisers/promoters/managers, land and track owners/managers/administrators/lessees, CAMS affiliated clubs, state and territory governments
and insured listed in CAMS’ public/product/professional indemnity insurance policies and each of their related bodies corporate (including their related bodies corporate) and each of
their organs and agencies, officers/president/directors/executives, employees, servants, agents, partners, providers, members, competitors, drivers, co-drivers, navigators, officials, crew
members, pit crew, delegates, licence holders, representatives, commissions, committees, advisers, trustees, councils, panels, shareholders, volunteers, officials, appointees, delegated
bodies and sponsors.
d. “Motor Sport Activities” means any motor sport activities or Recreational Services which are permitted or approved which CAMS regulates or administers by CAMS or otherwise under
the responsibility / control of CAMS;
e. “Reckless Conduct” means conduct where the supplier of the recreational services is aware, or should reasonably have been aware, of a significant risk that the conduct could result
in personal injury to another person and engages in the conduct despite the risk and without adequate justification;
f. “Recreational Services” means (unless otherwise defined in this document) services that consist of participation in:
a) a sporting activity; or
b) a similar leisure time pursuit or any other activity that:
(i) involves a significant degree of physical exertion or physical risk; and
(ii) is undertaken for the purposes of recreation, enjoyment or leisure.
www.cams.com.au
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ANY APPLICANT MAKING A FALSE DECLARATION IS LIABLE TO REFUSAL AND
CANCELLATION OF LICENCE AND/OR INSURANCE COVER
Declaration
I accept the conditions of, and acknowledge the risks arising from, attending or participating in Motor Sport Activities being provided by CAMS
and the Entities. I agree to be bound by the rules, regulations and policies of CAMS at all times as a condition of continuing to hold a licence.
The information I have entered into this form is true and correct and I will advise CAMS immediately if any of the information I have given is no
longer true and correct. I have read, understood, acknowledge and agree to the above including the exclusion of statutory guarantees, warning,
assumption of risk, release and indemnity.
Signed:
SIGN HERE
Date:
For persons under the age of 18 years the following parent/guardian consent must be completed.
PARENT/GUARDIAN CONSENT – PERSONS UNDER 18 YEARS OLD
I ____________________________________________________________ of _______________________________________________________________
am the parent/guardian (Delete non applicable) of the above-named (‘Minor’) who is under 18 years old. I have read this document and
understand its contents, including the exclusion of statutory guarantees, warning, assumption of risk, release and indemnity, and have explained
the contents to the Minor. I consent to the Minor attending or participating in the event at his or her own risk.
Signed:
SIGN HERE
Date:
IMPORTANT NOTE: if applicant is under the age of 18, please read CAMS Junior Officials policy which is available on the CAMS website.
Your Privacy
CAMS requires the above information to assess your application for a licence and, if successful, to provide you with CAMS’ services. The
information provided by you may be used and disclosed to others by CAMS for the purposes of CAMS’ business. CAMS may not be able to
issue a licence to you if you do not provide all of the information requested above. Full details of CAMS’ privacy policy (including how you can
access and correct your personal information and make a complaint) are available at CAMS’ website (www.cams.com.au.)
CAMS and its partners may send you direct marketing materials from time to time. This is in addition to relevant information which CAMS may
send to you as part of CAMS’ services.
Please tick this box if you do not want to receive direct marketing from CAMS or its partners.
Please return to:
CAMS
MEMBER SERVICES
PO BOX 427
CAULFIELD EAST, VIC, 3145
or email to: [email protected]
www.cams.com.au
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Notes for Application and Renewal of Licences
INFORMATION FOR ALL LICENCE APPLICATIONS
Discipline-specific Licences
If you compete in more than one licence discipline, eg Circuit Racing and
Rallying, you must have all licence categories included on your licence.
Pre-licence requirements must be met before any category can be added
to the licence.
Licence Expiry Dates
At first issue, competition and driver licences, except International, will have
12-month expiry dates which will be the last day of the month in which the
licence was issued; ie, a licence application processed on 15 August, will
have an expiry date of 31 August the following year, and this will become
the permanent expiry date.
Renewed licences will maintain their existing expiry date.
International licences will expire on 31 December of the year of issue to
comply with FIA regulations.
Licence Photographs
First time applicants for all club national and International applicants
should include a recent head and shoulders photograph of passport
quality, approximately 40mm x 50mm. This photo will be used on your
CAMS licence.
Photographs will be stored electronically by CAMS and licence holders will
be advised, with renewals, when photographs need to be updated.
CAMS Manual of Motor Sport
Applicants for all licence types have the option to receive an abridged
copy of the current CAMS Manual of Motor Sport at no charge. A full
version of the Manual can be found online at www.cams.com.au
Pass Books
A CAMS Pass Book will be issued to new licence holders to provide
details of satisfactory completion of licence upgrade and maintenance
requirements and of any penalties applied following judicial procedures.
The Pass Book can also be used by licence holders to maintain a
competition history. On licence renewal or upgrade of an existing licence
an updated licence sticker will be provided to those who have previously
been issued with a Pass Book.
Licence Performance and Skill Criteria
The performance and skill criteria for competition licences vary between
motor
sport disciplines.
Applicants should ensure that they meet the appropriate criteria – refer to
the
Performance and Skill Criteria in the CAMS Manual of Motor Sport online
at www.cams.com.au
Competitor Licences – Levels J, K, L, M, N & O
(Separate application form required)
Competition vehicle owners who are not the holders of a driver/competitor
licence must hold either a Level J, K, L (national) or M, N, O (international)
entrant licence.
Competitor licences may be issued to individuals, companies, groups and
teams who are the holders of current CAMS log books.
Sponsor and team names may appear in programs and results without
a licence being held. A club affiliated with CAMS may be shown in the
program, results etc as the competitor without being required to hold an
entrant licence.
New applications and advice of company name change must be
accompanied by a certificate of incorporation, registration, ACN or
business name.
International Licences
(information extracted from Appendix L to the Intl Sporting Code of the
FIA)
Regardless of the category of licence held, Australian nationals participating
in international competition overseas must also hold a CAMS-issued visa
which authorises them to participate in the competition noted on the
visa. The highest form of CAMS licence issued is an International Driver/
Competitor Licence, which is required to compete in events of international
status both in Australia and overseas.
Information can be obtained from CAMS Manual of Motor Sport, Licences.
required to provide documentary evidence of your Australian residential
status. This can inlude:
• Appropriate section of your passport
• Utility bill showing your residential address
• Statutory declaration indicating that you are a resident of Australia
Medical fitness
Applicants for CAMS competition licences must comply with CAMS
medical criteria relevant to their competition level.
Where applicants do not meet the criteria, medical records may be
requested by CAMS for referral to State Medical Assessors for a decision
on competition fitness.
Applicants will be advised by CAMS if their medical examination or
statement has not met CAMS medical criteria.
It is strongly recommended that all licence holders are vaccinated, where
possible, against blood borne diseases, eg Hepatitis B etc.
Medical Examiners
Not applicable to National Off Road and National Rally Licences
Medical Examinations may be conducted by any registered General
Practiioner.
When making an appointment, please advise that time will be required
for a full CAMS medical examination. The Health Statement form must be
completed by you prior to the appointment and the medical examination
record will be completed by the Medical Examiner.
The form must be signed by both you and the Medical Examiner. Make
sure you take the completed Medical Examination form with you when you
leave and forward it with your licence application, photograph and fee to
CAMS.
Lectures and Observed Licence Test
For the differing disciplines, new competitors are required to undertake
lectures and the necessary number of Observed Licence Tests.
Lectures are completed via the Internet.
To undertake a lecture via the Internet, the competitor provides details of
a current e-mail address in the application form. Further information will
be forwarded to this address. This email will contain a web-link, username
and password. The module I.D. number and password are requested on
the lecture entry screen.
The lecture is undertaken by following the prompts and completing the
multiple-choice test as you go.
Observed Licence Test can be arranged by contacting CAMS on 1300 883
959.
Application Advice
In order to complete the efficient production of your licence please
consider the
following:
• Answer all the questions, they are all important.
• Take your time. Although the information may not have changed, its
confirmation ensures that the data we hold is correct.
• Check if you need a medical examination. This will be detailed in the
Medical Assessment section of the application form.
• If you do take a prohibited or restricted drug, it does not necessarily
mean you cannot compete. Please refer to the ASADA website at www.
asada.gov.au.
• All competitors regardless of discipline must complete a Health
Statement, each and every year.
• Please use current forms. They are available on the CAMS website.
Nationality
Applicants who are not Australian citizens must have the authority of
the National Sporting Authority of the country of their passport prior to
a licence being issued. As required by the Federation Internationale de
l’Automobile (FIA). CAMS can arrange this, but it does take time. You are
www.cams.com.au
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Medical
Examination Record Not applicable to National Off Road & National Rally Licences
(must be completed by a Medical Practitioner registered to practice medicine in Australia)
Important If significant abnormalities are found, please obtain specialist opinion or pathology as indicated and return
with this form. If doubtful, refer to CAMS Member Hotline — 1300 883 959.
NOTES:
1. Photo ID required.
2. Please attach any Specialists’ reports or any pathology or radiology results relevant to this application.
3.If the applicant wears contact lenses, please attach to this report a certificate from the Ophthalmic Practitioner who
fitted them, stating their (i) stability, (ii) duration of daily use and (iii) condition.
4. BMI
(i) The Body Mass Index is weight (in kilograms) divided by the square of the height (in metres).
(ii) 20-25 Acceptable – normal range
25-30 Health risk area
high risk
30-35 Obese
35-40 Morbidly obese
5.References to Cardiovascular or CV score allude to the Framingham Study.
6.The “normal” answer to each question below is “NO”. In respect of each “YES” response, further details should be
provided in Examiner’s Comments.
}
Member’s name:
Member (licence) no:
What is the applicant’s:
Height (in cm)
Licence level:
Weight (in kg)
Body Mass Index
CV Score
Reference to CV Score chart also required for all applicants.
ENT System
Cardiovascular System
Is there any evidence of past or present vestibular
What is the pulse rate? (MAX 100)
disturbance, including intermittent conditions?
Yes
No
Is the rhythm abnormal?
/
What is the blood pressure? (MAX 150/90)
Are the peripheral pulses abnormal?
Yes
No
Is there any evidence in the history or examination
of past or present ischaemic heart disease?
Yes
No
ECG
Yes
Fasting LIPIDS
No
Is there any abnormality of the ENT system on
clinical examination?
Yes
No
Visual System
Has the applicant any evident abnormality
of the eyes?
Yes
No
Are contact lenses worn?
(Certificate of Ophthalmic Prac. required if YES)
A resting ECG is required with all Medical Examinations.
For International Licence applicants, a Stress ECG is
required every second year (complete ‘2’ over page).
ECG abormal?
Yes
Has the applicant undergone refractive surgery?
(Certificate of Ophthalmic Practitioner required if YES)
R
No
E
N
O
I
Y
L
ON
Visual Acuity
Test each eye separately with letter chart at 6m
Record in metric Snellen notation: eg, 6/9
Record number of errors made in smallest line read: eg, 6/9 -3RE LE
LDL
HDL
IT
T
C
A
R
LP
Fasting GLUCOSE
Unaided (without contact lenses or spectacles)
6/
6/
Respiratory System
Is there any abnormality of the respiratory system
on examination?
Is the applicant a smoker?
ICA
6/
6/
Abdomen
Is there any abnormality of the abdomen
on clinical examination?
Yes
No
ED
M
Y
B
D Yes No
E
ET
L
P
M
O
With spectacles or contact lenses
Urinary Examination
Does the applicant’s urine contain Protein
Yes
No
Visual fields
Do a confrontation test for each eye separately.
Is there any ocular or general medical history that
suggests the possibility of visual field loss?
Yes
No
Does the confrontation test suggest a loss of visual
fields in either eye?
Yes
No
Yes
Yes
Yes
No
No
No
Colour vision
Test with Ishihara for first licence only.
More than three (3) errors is a FAIL indicating abnormal colour vision.
Yes
No
2. Is there any impaired functional use,
either from 1 (above) or otherwise?
Yes
No
Has the applicant impaired use or movement of any
limb, joint, hand or foot which might impair or
compromise control of a motor vehicle?
Yes
No
Central Nervous System
Is there abnormality of the cranial nerves, limb tone,
power or co-ordination or tendon or plantar
response on examination?
If YES, the applicant will most likely need to be referred for a full eyesight
examination by an optometrist or an ophthalmologist
or
when visual acuity (with glasses if any or unaided if no glasses) is:
– less than a full 6/7.5 in either eye (International Licence)
– less than 6/9 -2 in the better eye or less than 6/18 -2
in the other eye (National Licence)
Yes
No
Is there any sensory impairment?
Yes
No
EC
B
O
T
Glucose
Other abnormality?
Locomotor System
1. Physical deformity, amputation or use
of any orthopaedic appliance?
Ishihara test failed?
Yes
No
The applicant should contact CAMS to obtain a copy of the Vision
Report Form to be completed by the optometrist or ophthalmologist they consult. When completed, the form should be returned to
CAMS and included with the Medical Examination Record. CAMS will
take into account the optometrist/ophthalmologist report when determining the applicant’s fitness to participate in motor sport.
Please ret urn to: MEMBER SERVICES, PO BOX 427, CAULFIELD EAST, VIC 3145
or email to: [email protected]
www.cams.com.au
C O N F E D E R AT I O N O F A U S T R A L I A N M O T O R S P O RT - PA G E 8
1300 883 959
Medical Examination Record
Examiners Comments:
1
On history:
2
On examination:
Stress ECG (INT’L ONLY)
Attach ECG Report.
Other comments:
Y
Normal
/
L
N
O
R
E
N
IO
Abnormal
If abnormal, date completed:
IT
T
C
A
R
LP
A
C
I
D
3
E
M
Y
Are there any unfavourable traits in applicant’s personality, revealed by history, appearance or behaviour?
D
TE
B
E
L
P
M
4
Has the applicant been prescribed drugs which are in contravention of the CAMS Anti-Doping policy, or inhaled asthma medications?
If so, please advise drug, dosage and reason:
TO
5
ment
O
C
E
B
In your opinion, is the applicant fit to participate in motor sport?
Yes
No
Yes
No
Further assess-
Statement by registered General Practioner
I have personally examined the applicant on
/
Yes
Are you the applicant’s normal GP?
/Signature:
No
Photo ID sighted
MEDICAL
EXAMINERS
STAMP
Name and address of medical examiner:
This medical is only valid for 3 months from the date of examiners signature
Member Services and State Medical Assessors Use Only
CAMS Member No.
Next Exam Due
Int
Medical every
year
Medical details to be entered on licence:
Visual Correction required?
Yes
Nat
Unfit
Medical every
two years
No
Other (please specify):
Assessor’s signature
Date
Please ret urn to: MEMBER SERVICES, PO BOX 427, CAULFIELD EAST, VIC 3145
or email to: [email protected]
www.cams.com.au
C O N F E D E R AT I O N O F A U S T R A L I A N M O T O R S P O RT - PA G E 9
1300 883 959