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Motor Cycling Ireland (incorporating M.C.U.I)
1 Day License - Tinahely Enduro 30th October 2022
Please read and complete all sections.
By submitting this application I agree to abide by the G.C.R's and rules of the Motor Cycle Union of Ireland. I confirm that I am medically fit and capable of having full control of a motorcycle taking part in a motorcycle competition run under M.C.U.I rules. I have attended a seminar or been briefed on the anti-doping code.
Name
*
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Last
Address
Street Address
Address Line 2
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New Zealand
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Tonga
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Algeria
Angola
Benin
Botswana
Burkina Faso
Burundi
Cameroon
Cape Verde
Central African Republic
Chad
Comoros
Democratic Republic of the Congo
Republic of the Congo
Djibouti
Egypt
Equatorial Guinea
Eritrea
Ethiopia
Gabon
Gambia
Ghana
Gibraltar
Guinea
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Kenya
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Libya
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Mali
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Mauritius
Morocco
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Namibia
Niger
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Senegal
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Sudan
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Tunisia
Uganda
Zambia
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Country / Region
Contact Phone Number
*
Contact Email
*
You must be over 16 years of age in order to apply for a 1 Day Licence. Please confirm that you are over 16 years of age.
*
Yes
Date of Birth
*
DD
/
MM
/
YYYY
Club Membership
In order to take out a 1 Day Licence you must be a member of a club affiliated to Motor Cycling Ireland. Please state what club you are a member of or if not currently a member of a club you can join TORC via the website www.torcireland.ie
Please state the club you are a member of
*
Medicat Certificate
Loss of consciousness for any reason, dizziness or headach?
*
Yes
No
Eye trouble? (except glasses)
*
Yes
No
Asthma?
*
Yes
No
Allergy to medicines or drugs?
*
Yes
No
Diabetes?
*
Yes
No
Heart Trouble?
*
Yes
No
Blood Pressure Disorder?
*
Yes
No
Stomach Trouble? (ulster, etc.)
*
Yes
No
Trouble with Limbs? (including muscle cramp or joint stiffness)
*
Yes
No
Epilepsy or Convulsions?
*
Yes
No
Mental or Nervious Disorder?
*
Yes
No
Uro-Genital Trouble?
*
Yes
No
Blood Disorder with tendency to bleeding?
*
Yes
No
Operations?
*
Yes
No
Do you regurarly take medicine or Drugs?
*
Yes
No
Other Illnesses?
*
Yes
No
If you have answered "Yes" to any of the above questions please provide additional details here.
RIDER DECLARATION
I have not been banned on medical grounds from taking part in any other sport.
*
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I do not take drugs and I do not abuse alcohol.
*
.
In case of emergency, I authorise any qualified person to administer the necessary treatment, medical and or surgical, including the administration of blood or blood products. I also agree to information concerning my medical condition being givem by the Doctor in charge to the Clerk of the Course, and to my own Doctor and relatives.
*
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I declare that the information that I have given is true
*
.
I agree to the information on the Medical Examination form being sent to the doctor of my FMN
*
.
Total
€22.00