BRISBANE MOTORCYCLE CLUB INC.
WILL CONDUCT
2015
QLD CLASSIC AND POST CLASSIC
MOTOCROSS CHAMPIONSHIPS
ON JUNE 13TH AND 14TH
SUPPLEMENTARY REGULATIONS
MEETING NAME
VENUE
DATE
QLD CLASSIC AND POST CLASSIC
MOTOCROSS CHAMPIONSHIPS
104 OLD WARICK ROAD
SATURDAY JUNE 13TH
HARRISVILLE QLD
SUNDAY JUNE 14TH
PROMOTER
MA TRACK LICENCE NO.
MA PERMIT NO.
BRISBANE MOTORCYCLE CLUB INC.
MQ183
51427
RACE SECRETARY
ADDRESS
CONTACT NO’S
DAVID TANNER
1 MEWSDALE ROW, TALLAI 4213
0459 122 090
STEWARD
KEVIN APPS
LES WATT
ANNOUNCEMENT:
The BRISBANE MOTORCYCLE CLUB INC., hereafter called the PROMOTER will conduct QLD CLASSIC AND POST CLASSIC
CHAMPIONSHIPS for SENIORS at 104 OLD WARICK RD; HARRISVILLE, on SATURDAY 13TH JUNE and SUNDAY 14TH JUNE.
1.
2.
2.1.
2.2.
3.
3.1.
3.2.
3.3.
3.4.
JURISDICTION:
The abovementioned meeting has been authorised by MQ who has issued the Motorcycling Australia Permit Number 51427 and is
open to holders of current Motorcycling Australia NATIONAL and SENIOR NATIONAL ONE MEETING Licences.
The meeting will be held in accordance with the current Manual of Motorcycle Sport General Competition Rules (GCR’s) , these
Supplementary Regulations, and any Final Instructions approved by MQ.
BY ENTERING THIS MEETING ALL PARTIES AGREE TO COMPLY WITH THESE RULES, REGULATIONS, BY-LAWS AND
INSTRUCTIONS.
ENTRIES:
Entries open forthwith to all Senior Licence Holders and will be accepted by email /mail up to last mail, Friday 5th June. If
by email Indemnity Form and payment must be made at sign on and before scrutineering.
In the case of postponement or Abandonment of the meeting, all or any part of the entry fee may be retained by the BRISBANE
MOTORCYCLE CLUB INC., if such retention is approved by MQ.
Only entries received on the official Entry Form that is accompanied by the correct fee will be accepted.
NOTE:- LATE ENTRIES WILL NOT BE ACCEPTED AND THE RETURN OF ENTRY FEES FOR ANY RIDER WITHDRAWING
FROM THE MEETING IS AT THE DISCRETION OF THE BRISBANE MOTORCYCLE CLUB INC.
4.
4.1.
4.2.
4.3.
INSURANCE:
National Personal Accident Scheme provides basic cover for death and permanent disability.
Ambulance Insurance is compulsory for licensees.
IT IS STRONGLY RECOMMENDED THAT COMPETITORS GIVE CONSIDERATION TO TAKING OUT WEEKLY BENEFITS
INSURANCE.
5.
MEDICAL SERVICES:
‘EMT’ Medical Services will be in attendance from start of practice until end of racing both days.
6
6.1.
6.2.
6.3.
7
CLERK OF THE COURSE
ENTRY FEE:
$70 includes 1 class plus, $10 for each additional class
$20 per Transponder NOTE: IF YOU OWN YOUR OWN TRANSPONDER/S PLEASE INCLUDE YOUR TRANSPONDER NUMBER/S ON ENTRY FORM
Payment by CASH, CHEQUE or MONEY ORDER only. ANY FEES FOR DISHONOURED CHEQUES WILL BE THE
RESPONSIBILITY OF THE ENTRANT.
Cheques and Money Orders are to be made payable to the BRISBANE MOTORCYCLE CLUB INC.
ENTRY PASSES:
N/A
8
CLASSES OF COMPETITION:
Pre 60
Solo All Powers All ages
Pre 65
Solo 250cc All Ages
Pre 65
Solo 263cc – over All Ages
Pre 70
Solo 250cc All Ages
Pre 70
Solo 263cc - over All Ages
Pre 75
Solo125cc All Ages
Pre 75
Solo 250cc All Ages
Pre 75
Solo 263 – over All Ages
Pre 75
4 – stroke All Powers All Ages
Pre 78
Solo 125cc All Ages
Pre 78
Solo 250cc All Ages
Pre 78
Solo 263 – over All Ages
Pre 78
Women’s - All Powers
Evolution
Solo 125cc All Ages
Evolution
Solo 250cc All Ages
Evolution
Solo 263 – over All Ages
Pre 85
Sidecar up to 1300cc
Pre 85
Solo 125cc All Ages
Pre 85
Solo 250cc All Ages
Pre 85
Solo 263cc – over All Ages
Pre 90
Solo 125cc All Ages
Pre 90
Solo 250cc All Ages
Pre 90
Solo 263cc – over All Ages
Pre 90
4 – stroke All Powers All Ages
Women’s race All Powers up to and including Pre 90
Superior Seniors 70+ yrs All Powers Classics Only
Age categories for Pre 75 and Evolution pointed separately.
9
AWARDS AND PRIZEMONEY:
TROPHIES WILL BE PRESENTED AT END OF RACING ON SUNDAY
NO PRIZE MONEY AT THIS MEETING
10
ENTRIES TO CONSTITUTE A CLASS:
10.1. To constitute a Class, the number of contestants entered and competing in each Class shall be as per the 2015
MOMS.(16.2.2)
10.2 Should there be insufficient entries in any Class of Competition, the decision to run or cancel the Class, or to combine events
and re-distribute any awards and / or prizemoney, will be at the discretion of the BRISBANE MOTORCYCLE CLUB INC.,
subject to MQ approval.
11
RACE FORMAT:
Each class will be raced in three {3} Rounds of three {3} laps, conditions and circumstances permitting. There will be no
semi finals or finals with all points awarded being tallied following the last race of the meeting.
12
MACHINES AND RIDERS:
12.1.
All machines entered must comply with the current GCR’s for CLASSIC and POST CLASSIC MOTOCROSS Competition.
12.2.
Multiple entry of the one Machine in the same Class of Competition is not permitted.
12.3
Change of Rider and Machine may be permitted if submitted in writing to the Clerk of the Course and with the approval
of the MA Steward prior to the start of the event in which the substitution is requested. Substitute machine must have
been passed at machine examination. Failure of riders to follow this procedure may result in placing not being
recorded.
13.
13.1.
13.2.
RIDING NUMBERS:
Wherever possible, competitors will be allocated their Registered Riding Number or their preferred Riding Number. All others will
be allocated numbers at the discretion of BRISBANE MOTORCYCLE CLUB INC.
All Number Plates on all Machines MUST comply with the GCR’s.
14
GRID POSITIONS:
There will be no allocation of Grid Positions {first in first choice}
15
RIDERS BRIEFING:
A Riders Briefing will be held prior to the commencement of racing and ALL Competitors MUST attend the Riders Briefing. Details
will be included in Final Instructions. RIDERS BRIEFING IS A NON SMOKING AREA.
16
DRUG AND OR ALCOHOL TESTING:
16.1
16.2
All competitors and officials are advised that as part of the MA drug education program, drug testing may take place at any
competition in accordance with Australian Sports Commission policy as implemented by the Australian Sports Drug Agency.
If any doubts exist over banned substances it is recommended competitors telephone the Drugs in Sport Hotline 1800 020506.
When drug testing takes place, the payment of prizemoney may be delayed at the [INSERT RCB] discretion until the results of
the tests are known.
17
CODE OF CONDUCT:
All Competitors, Officials and Parents are reminded of the Motorcycling Australia By-Law - CODE OF CONDUCT (as stipulated in the
GCR’s) which is a guide to appropriate behaviour at all Motorcycle Race Meetings. This CODE OF CONDUCT applies to this
Meeting and will be enforced.
18
TIMETABLE:
FRIDAY:
Sign on and Scrutineering
2 pm – 4pm
SATURDAY:
Gates Open
6.30am
Scrutineering
7am - 8am
Sign on
7am – 8am
Officials Briefing
8am – 8.15am
Riders Briefing
8.15am – 8.30am
Practice
8.30am – 9.30am
Racing
9.30am
Gates Open
6.30am
Sighting lap {1}
8.15am – 8.30am
SUNDAY:
Officials Briefing
8am – 8.15am
Racing
9am
Awards presentation 1 hr after final Race
Riders will be able to walk the track prior to, and during Scrutineering.
For the purposes of drug & alcohol testing, the commencement of the meeting will be deemed to be 7am with the completion of the
meeting for the participant being when the participant has vacated the venue.
19
CIRCUIT DESCRIPTION:
Approx 2000 meters of natural terrain track with man made features.
20
STARTS:
1 minute after the last rider passes the chequered flag on the track from the previous race; or at the Starters discretion;
15 sec Board;
5 sec Board;
Self Penalising Falling Gates.
21
RACING:
Practice will consist of 15 min periods for all 125’s; all 250’s; all 263cc – over; and all Sidecars.
Racing will consist of three {3} Rounds of three {3} Laps, conditions and circumstances permitting.
All Races and Practice will be run in a clockwise direction on the track.
Racing Program will be announced on the day at the Riders Briefing.
22.
NOISE:
Limit dB(A) 95 {30meters from the side of the track} as per MOMS 16.12.1.1, 2015
23.
GST:
N/A
24.
LICENCES:
All Riders must produce their MQ Licences to compete;
One Event Licences are available at a cost of $80 through Motorcycling Queensland.
All Licences will be held as security for the transponders and may be redeemed when the transponder is returned.
One Event Licence holders will also be required to leave their Driving Licence/18+Card, which may be redeemed when the
transponder is returned.
25.
MYLAPS:
All races will be timed through the MYLAPS system.
There is a fee equivalent to the replacement cost for lost or damaged transponders
26.
FACILITES:
Overnight camping is available at no cost {Friday and Saturday night}
Toilets and hot showers are available
Food and Drinks can be purchased on Saturday and Sunday from the Volunteer Fire Fighters, at the Venue.
BRISBANE MOTORCYCLE CLUB INC.
WILL CONDUCT
2015
QLD CLASSIC AND POST CLASSIC
MOTOCROSS CHAMPIONSHIPS
ON JUNE 13TH AND 14TH
ENTRY FORM
Entrant:
MA Lic. No:
MA Lic. Expiry Date:
Rider’s Surname:
Rider’s First Name:
MA Lic. No:
MA Lic. Expiry Date:
Address:
Post Code:
Club:
Grade:
If under 18 years – Date of Birth:
Registered Competition No:
:
If Not Registered, Preferred No:
(Home)
(Work)
(Mobile)
Next of Kin Contact No:
Passenger’s Surname:
Passenger’s First Name: ………………………………………...
MA Lic. No:
MA Lic. Expiry Date:
Address:
Post Code:
Club:
Grade:
If under 18 years – Date of Birth:
Registered Competition No:
:
(Home)
If Not Registered, Preferred No:
(Work)
(Mobile)
Next of Kin Contact No:
EVENT
MACHINE
CAPACITY
AGE
I ACKNOWLEDGE THAT THIS MEETING WILL BE HELD IN ACCORDANCE WITH THE CURRENT GENERAL COMPETITION RULES (GCR’S) THESE
SUPPLEMENTARY REGULATIONS (OF WHICH THIS ENTRY FORM FORMS PART OF) AND ANY FINAL INSTRUCTIONS. BY ENTERING THIS MEETING ALL
PARTIES AGREE TO COMPLY WITH THESE RULES, REGULATIONS, BY-LAWS AND INSTRUCTIONS.
ENTRY FEES:
$70 includes 1 class plus, $10 for each additional class; plus$20 per Transponder.
TOTAL PAYABLE = $
NOTE: IF YOU OWN YOUR OWN TRANSPONDER/S PLEASE INSERT YOUR TRANSPONDER NUMBER/S #________________
RIDERS NAME
SIGNATURE
DATE
PASSENGERS NAME
SIGNATURE
DATE
PARENT / GUARDIAN NAME
SIGNATURE
DATE
PLEASE TICK ONE
I AM A PROFESSIONAL RIDER AND MY ABN IS: ______________________________
MOTORCYCLE SPORT IS MY HOBBY WHICH IS THE REASON I AM NOT QUOTING AN ABN
PARTICIPANT DECLARATION
Motorcycling Queensland
PO Box 2072, North Ipswich Q 4305
Ph:07 3281 2255 Fax:07 3812 2742
Email: [email protected] Web: www.mqld.org.au
CONTRACT TO PARTICIPATE IN THE QLD CLASSIC AND POST CLASSIC MOTOCROSS CHAMPIONSHIP
WARNING! THIS IS AN IMPORTANT DOCUMENT WHICH AFFECTS YOUR LEGAL RIGHTS AND OBLIGATIONS, PLEASE READ IT CAREFULLY AND DO NOT SIGN IT UNLESS
YOU ARE SATISFIED YOU UNDERSTAND IT.
For the purposes of the clause 3, “the Supplier” shall mean and include
facility providers of MA / SCB permitted events, and generally to
1. I THE UNDERSIGNED (see below):
[Insert Name]
the Indemnitees.
reduce the risks to persons engaged in motorcycle sport; and
iii) It is reasonable for MA and my SCB to collect, store, use and disclose my
5. INDEMNITY AND RELEASE GIVEN TO ORGANISERS
HEREBY AGREE with Motorcycling Australia Limited (“MA”) that I am by
Information in accordance with clause 11(a)(i) above and in the manner set
IN CONSIDERATION of the acceptance of me as a participant in the
this agreement entitled to participate in the motorcycle activity/meeting
out in clause 11(b).
Meeting:
listed in Schedule 2 (hereinafter called "the Meeting" or the “Event”) at the
b) IN CONSIDERATION of my acceptance as an entrant in the Meeting
a) I AGREE TO INDEMNIFY AND KEEP INDEMNIFIED to the full
venue listed at Schedule 3 (hereinafter called "the Venue") on the terms
I consent and agree that MA and my SCB:
extent permitted by law the Indemnitees and each of them in the
and conditions set out in this document.
i) may collect and store any of my Information, including obtain my
following manner:
Information from third parties including my Carers;
2. DEFINITIONS In this declaration:
i) that I participate in the meeting at my sole risk and responsibility;
ii) may use any information collected in accordance with this clause for
a) “Claim” means and includes any action, suit, proceeding, claim,
ii) that I accept the Venue as it stands with all or any defects hidden or
any purpose consistent with creating safer competition in motorcycle
demand, damage, cost or expense however arising including but not
exposed;
sport and events held by or in conjunction with MA, my SCB, or with
limited to negligence but does not include a claim against a
iii) that I indemnify and hold harmless the Indemnitees, their respective
an MA or SCB permit;
Motorcycling Organisation under any right expressly conferred by its
servants, agents, officials and competitors against any actions,
iii)
may disclose my Information to third parties provided such disclosure is
constitution or regulation;
costs, losses or claims which may be made by me or on my behalf
reasonably intended to be used for the purpose of improving safety at
b) “Indemnitees” means and includes the persons, organisations and
for or in respect of or arising out of my death or any injury loss or
events held by or in conjunction with MA, or with an MA permit provided
bodies corporate whose names appear in Schedule 1.
damage caused to me or my equipment whether caused by
any such information is held by MA or my SCB in accordance with the
c) “MA” means Motorcycling Australia Limited;
negligence, breach of contract or in any other manner whatsoever.
MA Privacy Policy.
d) “State Controlling Body” (SCB) means a state or territory
b) I AGREE TO RELEASE to the full extent permitted by law the
c) I irrevocably authorise MA and my SCB and hereby appoint MA and my
motorcycling association affiliated as a member of MA;
Indemnitees and each of them from all liability to me for any claim,
SCB as my lawful attorneys to collect from my Carers, and I hereby direct
e) “Motorcycling Activities” means performing or participating in any
loss, damage, cost or expense (whether arising under statute, from
my Carers to provide to MA or my SCB upon request being made by MA
capacity in any authorised or recognised Motorcycling Organisation
negligence, personal injury, psychological trauma, death, property
or my SCB, any of my Information including but not limited to any
event, meeting or activity;
damage or infringement of third party rights or otherwise) that arises
information concerning any incident or event causing or contributing to or
f) “Motorcycling Organisation” means and includes MA, and the MA
as a result of any act, matter or thing done, permitted or omitted to
resulting from any injury, illness or death to me, the details of any diagnosis
members (including the SCBs and affiliated clubs) and where the
be done by me or which is in any way connected with my presence
and prognosis provided to me by my Carers (or any party with the
context so permits, their respective directors, officers, members,
at or involvement in the Event.
knowledge of any of my Carers), and any other matter to the knowledge of
servants or agents.
c) The release and indemnity provided by me in this declaration is in addition
my Carers that might reasonably be considered to be requested by MA or
to, and will not in any way limit the application of, the conditions of sale
3. ACKNOWLEDGMENT OF RISKS, DANGERS & OBLIGATIONS
my SCB for the purpose of improving safety at MA and SCB events.
attaching to tickets, conditions of entry, conditions of credentials or any
I ACKNOWLEDGE that:
9. POLICIES AND REGULATIONS
other applicable terms or conditions in respect of the Event.
a) motorcycle sport is dangerous and that by engaging in the sport
d) A term of this release and indemnity will not apply where the term
a) I acknowledge, understand and agree that it is a condition of my
(whether as a competitor, recreational rider, coach, official or media)
contravenes the law of the relevant jurisdiction under which any legal
participation in the Event that I agree to be bound by, and subject to,
at the Meeting I take and am exposed to certain risks and dangers
action is legitimately taken however such terms are severable and do
the rules, regulations and jurisdiction of MA as amended from time to
and am under certain obligations as follows:
not invalidate the remaining terms.
time. Copies of all MA rules, policies and regulations are available
i) that I may be injured, physically or mentally, and may be killed;
by contacting the MA office.
ii) that my machinery or equipment may be damaged, lost or destroyed;
6. MEDICAL
b) All participants are bound by the MA anti doping policy and thus
iii) that competitors may ride dangerously or with a lack of skill;
I declare that I am and must continue to be medically and physically fit
understand they may be subject to drug testing. Testing conducted
iv) that track or event conditions may be hazardous and may vary
and able to participate in the Meeting. I will immediately notify MA in
by the Australian Sports Anti-Doping Authority (ASADA) is in
without warning or predictability;
writing via my SCB of any change to my fitness and ability to
accordance with the ASADA Act and the National Ant-Doping
v) that organisers, officials, landowners/track operators and any agents
participate. I understand and accept the Indemnitees will continue to
Scheme. This involves the taking of a sample (any human biological
or representatives of those in charge of meetings are frequently
rely upon this declaration as evidence of my fitness and ability to
fluid or tissue whether alive or otherwise, or any human breath) for
obliged to make decisions under pressure of time/or events;
participate.
the purpose of detecting the use of a Prohibited Drug or Doping
vi) that any policy of insurance of or in respect of my life or physical or
I acknowledge and agree that if required, the Indemnitees (or any of
Method. Any participant infringing MA’s policy or refusing a drug test
mental health may be voided;
them) may arrange medical or hospital treatment (including ambulance
may be disqualified or otherwise dealt with in accordance with the
vii) that there may be no or inadequate facilities for treatment or
transportation) for me. I authorise such actions being taken by the
terms of the anti-doping policy.
transport of me if I am injured;
Indemnitees and agree to meet all costs associated with such action. I
vii) that I have an obligation to myself and to others to act safely and
understand it is compulsory for me to have ambulance insurance in
10. RIGHT TO USE IMAGE
within the rules and regulations of MA;
some form and I accept responsibility for the cost of ambulance
Right to Use Image: I acknowledge and consent ot Photographs and
b) the Indemnitees do not make any warranty that the services at the
transportation, ambulance cover and further agree to maintain
electronic images (including, but not limited to, moving images)
Meeting will be provided with due care and skill or that any materials
ambulance cover during the term of my license / membership.
being taken of me during my participation in the Event. I
provided in connection with the services will be fit for the purpose for
acknowledge and agree that such photographs and electronic
7. PRIVACY
which they are supplied;
images are owned by (organisation) and it may use the photographs
I hereby consent to the collection of my personal information by the
c) to the extent that any warranty is implied it is excluded to the full
and electronic images for promotional or other purposes without my
Promoter/Event
Organiser,
MA
and
the
SCB
in
connection
with
my
extent permitted by law;
further consent being necessary. Further, I consent to (organisation)
involvement at the Event and the use and disclosure of my personal
d) have voluntarily read and understood this warning and accept and
using my name, image, likeness and also my performance in the
information by Event Organiser, and MA to other agencies and officials
assume the inherent risks in participating in the Event.
Event at any time, by any form of media, to promote (organisation) or
associated with the Event for the purposes of conducting and managing
the Event.
4. WARNING UNDER THE FAIR TRADING ACT 1999 (VIC)
the Event. I understand that I may gain access to my personal information
Under the provisions of the Fair Trading Act 1999 (Vic) several
SCHEDULE 1
held by contacting MA at 147 Montague St, South Melbourne, Victoria,
conditions are implied into contracts for the supply of certain goods and
3205. I understand that if I do not provide the personal information
1) Federation Internationale de Motocyclisme
services. These conditions mean that the supplier named on this form
requested above that I may not be permitted to participate in the Event.
2) Motorcycling Australia Ltd
is required to ensure that the recreational services it supplies to you are:
3) Motorcycling Queensland
8. PERSONAL HEALTH INFORMATION
- rendered with due care and skill;
4) Brisbane Motorcycle Club Inc.
I hereby agree with MA and the SCB that in consideration for my
- as fit for the purpose for which they are commonly bought as it is
5) Brisbane Motorcycle Club inc
participation in the Event that MA and the SCB may receive, collect, store
reasonable to expect in the circumstances; and
6) Greg Mitchel
and use personal health information about me in the manner set out
- reasonably fit for any particular purpose or might reasonably be
7) <Add Sponsor Here>
below:
expected to achieve any result you have made known to the
8) EMT
supplier.
a) I ACKNOWLEDGE that:
9) <Add Other Here>
Under section 32N of the Fair Trading Act 1999, the supplier is entitled to
i) If I am injured, become ill or die at or following the Event the party
10) All other persons involved in the organisation, conduct and
ask you to agree that these conditions do not apply to you. If you sign
listed at Item 8 in Schedule 1 in addition to any hospital at which I
promotion of the Event or construction or location of the facilities
this form, you will be agreeing that your rights to sue the supplier under
am treated (together “my Carers”) will have health related
used in connection with or otherwise related to the Event
the Fair Trading Act 1999 if you are killed or injured because the services
information about me intheir possession, power and control relating
11) Each of the respective officers, employees, servants, agents,
were not rendered with due care and skill or they were not reasonably fit
to me which is subject to obligations imposed by the Privacy Act
sponsors, successors and assignees of each of the above.
for their purpose, are excluded, restricted or modified in the way set out in
(“my Information”) and the Privacy Act is intended to protect my
SCHEDULE 2:
this form. NOTE: The change to your rights, as set out in this form, does
personal information;
Saturday 30th May 7am &Sunday 31st May 7am
not apply if your death or injury is due to gross negligence on the
ii) MA and my SCB wish to collect my Information for purposes that
SCHEDULE 3:
supplier's part. "Gross negligence" is defined in the Fair Trading
include their risk management programs, evaluating and improving
(Recreational Services) Regulations 2004.
the safety of MA and SCB events and of the Meeting organisers and
104
Old
Warick
Rd;
Harrisville
Qld.
14. EXECUTION
SIGN
HERE
I THE UNDERSIGNED STATE THAT I HAVE READ AND UNDERSTOOD THIS DECLARATION (INCLUDING THE WARNING,
INDEMNITY AND RELEASE) AND AGREE TO THE TERMS AND CONDITIONS AS STATED.
NAME (PRINT): ____________________________________ SIGNATURE: _____________________________________ DATE: _____________________
PASSENGER (PRINT): _____________________________ SIGNATURE: _____________________________________ DATE: _____________________
15. THIRD PARTY INDEMNITY WHERE PARTICIPANT IS UNDER 18 YEARS OF AGE
I/WE _____________________________________________________ being the parents or guardians of the person named in Clause 1 (hereinafter called "the entrant") HEREBY ACKNOWLEDGE:
a) I/we have read the whole of this document and understand it; b) I/we consent to the entrant participating in the Event; AND c)..I/we are aware of the risks, dangers and obligations set out in Clause 3 above; d)
I/we acknowledge that the entrant is bound by and subject to the rules and policies of MA, including, without limitation, the MA anti-doping policy.
16. IN CONSIDERATION of the entrant being accepted as a participant in the Meeting I/WE HEREBY INDEMNIFY AND RELEASE the Indemnitees in the same manner and to the same effect as if I/WE were the
entrant and agree to personally accept all terms and conditions and obligations set out in this declaration,
PARENT/GUARDIAN: ___________________________________________ SIGNATURE ____________________________________________DATE: ________________
PASSENGER’S PARENT/GUARDIAN:____________________________________ SIGNATURE _____________________________________ DATE: __________________