EmailMe Form - DJ RALLY 2022 Entry Registration Form

DJ RALLY 2022 Entry Registration Form

DJ RALLY DATES: FRIDAY 11th MARCH to SATURDAY 12th MARCH 2021

ENTRY CLOSING DATE: 31 JANUARY 2022
SAVVA PERMIT NUMBER: P31/2021
(Online form version: 19 DEC 2021)

IMPORTANT:

PLEASE COMPLETE THIS ONLINE APPLICATION IN FULL, WHICH INCLUDES EVERY PAGE. ON THE LAST PAGE THE SUBMIT BUTTON NEEDS TO BE CLICKED ON, TO ENSURE THAT THE APPLICATION HAS BEEN LOADED AND SENT SUCCESSFULLY. FAILING THIS, YOUR APPLICATION WILL NOT BE SUBMITTED TO THE ENTRY ADMINISTRATOR.

RIDER MUST COMPLETE THIS SECTION
First Time Rider *
Yes
No
Gender Rider *
Male
Female
Name *
First Last
Club Details *

Club Name

Membership No

Indemnity No VSR 24
Physical Address *

Address Line 1

Address Line 2

City (and Country if not SA)

Postal Code
ID / Passport Number *
Email Address *
Telephone Numbers *

Mobile

Home

Work
DJ Rally T-Shirt size *
RIDER MEDICAL INFORMATION MANDATORY
Blood Group *
Medical Information *

Medical Allergies (Bee stings, foods, medication, etc)

Current Medication (Blood pressure tablets, Asthma pumps, etc)
Medical Aid Details *

Medical Aid Company Name

Medical Aid Number

Medical Aid Type (Full, Comprehensive, Key Classic, etc) - Optional
In Case of Emergency Contact Details of the Next of Kin *

Name and Surname

Relationship

Mobile No
1 / 6

Address Line 1
Address Line 2
City (and Country if not SA)
Postal Code

Medical Allergies (Bee stings, foods, medication, etc)
Current Medication (Blood pressure tablets, Asthma pumps, etc)

Medical Aid Company Name
Medical Aid Number
Medical Aid Type (Full, Comprehensive, Key Classic, etc) - Optional

Club Name
Membership No
Indemnity No VSR 24

Mobile
Home
Work

Name and Surname
Relationship
Mobile No

RIDER MUST COMPLETE THIS SECTION

RIDER MEDICAL INFORMATION MANDATORY