EmailMe Form - V.S.B.C Online Entry Form

Name Of Event *

I.e Club Day, Eppalock Gold Cup, Kilos

Boat Name *

Class Entered *

Please select your appropriate class

Target *

Hull Type *

Inboard Only.

Unlimited

Injected

Carby

Restricted

Is your Engine Sealed? *

Yes

No

If Yes, Seal Number

Does your boat have a cell *

Yes

No

Boat Registration No *

Boat Registration Expiry *

DD / MM / YYYY

Motor Make & Model *

Capacity of Motor *

Hull Width in Metres *

Hull Length in Metres *

APBA Race Number *

APBA Log Book Number

APBA Tech Inspection Number *

Owners APBA Licence No *

Owners APBA Club *

Owners Name *

First Last

Owners Phone No *

Owners Address (Optional)

Street Address Address Line 2 City State / Province / Region Postal / Zip Code

Owners or Drivers Email *

Emergency Contact name

First Last

Emergency Contact Phone No

Drivers Section

Drivers Name *

First Last

Drivers Phone No *

Drivers Address (Optional)

Street Address Address Line 2 City State / Province / Region Postal / Zip Code

Drivers Email (Optional)

Drivers APBA Club *

Drivers APBA Licence No *

Drivers SBA Licence No *

Drivers SBA Licence Expiry Date *

DD / MM / YYYY

License Status *

Full

Probation

Emergency Contact name *

First Last

Emergency Contact Phone No *

Second Drivers Section

If applicable!

Second Drivers Name

First Last

Second Drivers Address (Optional)

Street Address Address Line 2 City State / Province / Region Postal / Zip Code

Second Drivers Phone No

Second Drivers Email

Second Drivers APBA Licence No

Second Drivers APBA Club

Second SBA Licence No

Second Drivers SBA Licence Expiry Date

DD / MM / YYYY

Second Driver License Status *

Full

Probation

Declaration by Owners:

To the Honorary Secretaries of VSBC, I / We *

Please insert owners name in the box above.

being the owner(s) of the abovementioned boat do hereby certify that the specifications of the boats' hull and motor are known to me/us to be in conformity with the Rules and restrictions governing the class of the event entered. I/We will comply with the APBA RACING and SAFETY RULES in their entirety. I/We declare that the above particulars are to my/our knowledge true and correct. *

Clear

Owners Please sign in the box above

Date Owner Signed *

DD / MM / YYYY

Drivers Signature

Drivers Signature.
NOTE I the undersigned realise that powerboat racing is dangerous. I do not rely on officials or this scrutineering for the safety of the boat or my equipment and realise this is my responsibility and that safety or other equipment required cannot guarantee me or my boats safety. If I have taken the decision to use a boat fitted with a Reinforced Cockpit or a Deflection Bar or a Belt Restraint or a combination of either or all three I personally have examined these items fitted to the boat and use them totally at my own risk and at my own choice and I realise that these may make the boat more dangerous in certain conditions. I on behalf of myself, and my heirs or any other person, release all persons and organisations connected with the running, supervision, or administration of the event from any responsibility whatsoever however caused. I sign this indemnity without duress and in the full knowledge that I may be giving up certain legal rights. *

Clear

Driver please sign in the box above

Date Driver Signed

DD / MM / YYYY

Second Drivers Please Sign below if applicable.

Second Drivers Signature.
NOTE I the undersigned realise that powerboat racing is dangerous. I do not rely on officials or this scrutineering for the safety of the boat or my equipment and realise this is my responsibility and that safety or other equipment required cannot guarantee me or my boats safety. If I have taken the decision to use a boat fitted with a Reinforced Cockpit or a Deflection Bar or a Belt Restraint or a combination of either or all three I personally have examined these items fitted to the boat and use them totally at my own risk and at my own choice and I realise that these may make the boat more dangerous in certain conditions. I on behalf of myself, and my heirs or any other person, release all persons and organisations connected with the running, supervision, or administration of the event from any responsibility whatsoever however caused. I sign this indemnity without duress and in the full knowledge that I may be giving up certain legal rights.

Clear

Second Driver please sign in the box above.

Date Second Driver Signed

DD / MM / YYYY

Amount to be paid *

Senior $150

Drivers Section

Second Drivers Section If applicable!

Declaration by Owners:

Drivers Signature

Second Drivers Please Sign below if applicable.

Second Drivers Section

If applicable!