EmailMe Form - DJ RALLY 2022 Entry Registration Form

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
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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