EmailMe Form - Motor Cycling Ireland (incorporating M.C.U.I)

Please read and complete all sections.

Name *

First Last

Address

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

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. *

.

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. *

.

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 *

.