National Enduro Championship (Round 1) Screening Questionnaire

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Event: Timberland National Extreme NESS
Date: 22 MAY 2021
Venue: Korongo Valley Guest Farm, D56 IXOPO
MSA Permit No: MSA

[Parents/guardians to complete this form on behalf of minor children]

Race Number *

Provide your race number or the race number of your team. Each team associated with a race number cannot constitute more than 6 people (Rider + 5)

Name *

Surname *

MSA License Number *

ID Number *

If you are a foreign competitor and you do not have a RSA ID number, please insert zero's and just complete your date of birth

Date of Birth *

YYYY

Cell number *

Gender

Female

Male

Clear selection

I am a ..... *

Competitor

Service crew member

Family member of competitor

Official

Please provide the details of the people that you live with (e.g. immediate family members in the same house) *

Please provide each person's name, surname, ID number, contact number & email address. MSA monitors the situation regarding the Coronavirus daily and follows directives from Government Health Authorities. The health and wellbeing of our community is our first priority. At this time, we will require you to answer this question in as much detail as possible. MSA reserves the right to deny anyone entry to the event.

Do you have any of the following symptoms? *

Yes

Cough

Sore throat

Nausea/Vomiting/Diarrhoea

Fever/Chills/High Temperature = 37.5

Loss of taste

Loss of sense of smell

Body aches

Fatigue/Weakness/Tiredness

Persistent pain or pressure in chest

Shortness of breath

If your answer to any of the above questions is "YES", please provide further information below.

Have you... *

If your answer to any of the above questions is "YES", please provide further information below.

Yes

Had contact with anyone with cold/flu like illness in the last 14 days?

Been diagnosed with the Coronavirus infections in the last 14 days?

Had contact with a confirmed COVID-19 case in the last 14 days?

If your answer to any of the above questions is "YES", please provide further information below.

I (in my personal capacity/my capacity as parent or guardian of my minor child) confirm that... *

The information provided in this questionnaire is true and correct.

I understand and acknowledge that in the event that I am not truthful about the information provided in this questionnaire, I will be guilty of a criminal offence.

By completing and submitting this form, I/we hereby indemnify and hold harmless Motorsport South Africa NPC, all entities associated with the promotion and organization of the competition, the owner/s of any property on which the competition is held, and their respective officials, agents, servants and representatives, against any legal liability should I/we contract COVID-19 during the competition, regardless of the precautions taken to mitigate the risk. I/we understand and accept that I/we am/are present at the event at my/our own risk.

I confirm that I have read the Covid Operation Plan and I agree to abide by the rules set out therein.

Required

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