Licence Application/Renewal

Circuit, Rally, Off Road - 2024

Use this form to apply/renew for the following
licences:
RECEIVED STAMP HERE • Circuit Licences
To avoid a processing time you can
renew on the member portal by
(OFFICE USE ONLY) • Rally Licences
visiting motorsport.org.au/login
• Off Road Licences
If you do not have an account you can register for
This form must be submitted to: Member Services, a member ID at motorsport.org.au/register
PO Box 172, Canterbury VIC 3126,
or emailed to [email protected]
Please ensure all sections are completed and signed where
indicated. All licences are valid for Speed activity.

MEMBER NUMBER

TYPE OF LICENCE APPLYING FOR

Details

SURNAME

GIVEN NAMES

DATE OF BIRTH ­— ­—

MALE FEMALE NON-BINARY DIFFERENT TERM PREFER NOT TO SAY

GENDER Please specify:

ADDRESS

SUBURB STATE POSTCODE

EMAIL

MOBILE

PHONE
Please attach
EMERGENCY CONTACT NAME (1) a passport
size photo
EMERGENCY CONTACT NUMBER (1) here
(if not previously
EMERGENCY CONTACT NAME (2) supplied)

EMERGENCY CONTACT NUMBER (2)

ARE YOU OF ABORIGINAL OR

NO YES, ABORIGINAL YES, TORRES STRAIT ISLANDER
TORRES STRAIT ISLAND ORIGIN?

DO YOU HAVE AN AUSTRALIAN

YES NO
CITIZENSHIP OR PERMANENT RESIDENCY?
If ‘NO’ to citizenship or permanent residency, what is your nationality of passport
If 'NO', you are required to provide documentary evidence of your Australian Status. This can include: Appropriate section of your
passport, utility bill showing your residential address, or a statutory declaration indicating that you are a resident of Australia.

Motorsport Australia Affiliated Club Membership

Please list the Motorsport Australia affiliated club of which you are a member (no abbreviations).
Note: It is compulsory for all Motorsport Australia driver licence holders to be a member of a Motorsport Australia affiliated
sporting car club.

FULL NAME OF CLUB STATE

OFFICE USE ONLY

MEMBER NUMBER DATE ­— ­—

RECEIPT NO. AMOUNT $

Motorsport Australia ABN: 55 069 045 665

Mail: PO Box 172 Canterbury LPO, VIC 3126
Phone: +61 3 9593 7777 Hotline: 1300 883 959 24/V1 pg. 1
motorsport.org.au © Confederation of Australian Motor Sport Ltd. trading as Motorsport Australia
Licence Application/Renewal
Circuit, Rally, Off Road - 2024

Motorsport Australia App

Your licence is now accessible on the Motorsport Australia App. This free app is available on the App Store and Google Play, and it is directly linked to your existing Motorsport Australia
Member Portal profile. You’ll no longer have to wait for your licence to arrive in the mail, and there’s no more carrying around another card in your wallet. Your Motorsport Australia licence is
now in the palm of your hand.
Contact the Member Services Team on 1300 883 959 or at [email protected] for more information.

Pre Licence Conditions

CIRCUIT RALLY OFF ROAD
All Circuit Licence applicants must complete the online All Rally Licence applicants must complete the All Off Road Licence applicants must complete
Circuit Racing Lecture (emailed by Member Services upon online Rally Licence Lecture (emailed by Member the online Off Road Licence Lecture (emailed by
receipt of application). Services upon receipt of application). Member Services upon receipt of application).
In addition to the Circuit Racing Lecture, applicants must In addition to the Rally Licence Lecture, applicants In addition to the Off Road Licence Lecture,
also complete an Observed Licence Test. must also complete an Observed Licence Test. applicants must also complete an Observed
An Observed Licence Test is not required if the applicant: ● Applicants over the age of 25 will not be Licence Test which can be completed at your first
required to complete an OLT if they have event.
● Has completed at least five Motorsport Australia
Supersprint or Regularity events, or two Motorsport held a civil drivers licence for five years or ● Off Road Navigators are not required to
Australia Tarmac Rally events in the previous 24 more. Proof of this is to be provided with the complete the OLT, and their licence will be
month period. Copies of the results must be included application (a photocopy of the licence card issued upon completion of the Off Road
with your application will be accepted) Licence Lecture
● Holds a current AKA B grade licence or higher. A copy ● Rally Navigators are not required to complete
of this licence must be included with your application the OLT, and their licence will be issued upon
completion of the Rally Licence Lecture

Renewal Conditions
For Circuit, Rally and Off-Road racing the applicant must have competed in at least one Motorsport Australia permitted event in the past four years for
each discipline. Please tick if the renewal conditions have been met and provide a record of previous participation (copy of competition licence passbook
or official race results are accepted records).
Applicants that do not meet this requirement will be required to complete an Observed Licence Test, or must meet the Pre Licence Conditions as stated in
the section above.

Licence Selection
AIMSS Contribution
If you do not wish to make a $10.00 contribution to AIMSS, please tick the box, and reduce your Grand Total by $10.00
Please note, a $10.00 AIMSS Contribution is included in adult licence fee (not applicable to junior licences).
The Australian Institute of Motor Sport Safety is a national not-for-profit organisation founded by Motorsport Australia, which is committed to improving safety in motorsport at all
levels in Australia. Visit aimss.com.au for more information.

CIRCUIT RALLY OFF ROAD

Circuit (16) $550.00 Rally (16) Off Road (16)

$332.00 $315.00
Navigator Only (16) Navigator Only (16)

Rally Junior (14) Off Road Junior (14)

$70.00 $70.00
Navigator Only (14) Navigator Junior Only (14)

Fee Options
Licence Card: $10.00 Competition Passbook: $10.00 Urgent Fee: $120.00
Your licence is now accessed on the Please tick if you would still like to Please tick if you require your licence
Motorsport Australia app, and can be receive a Competition Passbook and within 5 working days of being
displayed at all events. Please tick if you add $10.00 to the Grand Total. received by Motorsport Australia
would still like to receive a plastic hard please add $120.00 to the Grand Total
card and add $10.00 to the Grand Total. (not applicable for Junior licences).

Grand total should reflect the total of licence fee and options
GRAND TOTAL: $ selected. NOTE: if you are applying for more than one licence
type, please enter the value of most expensive licence only

Payment

Paying by (please tick appropriate box) Debit or Credit Card details

Cheque/Money Order Name on card
(Made payable to “Motorsport Australia”)
Card number
Debit or Credit Card
(Please complete details. Please note that American
Express is not able to be used for payment)
Card expiry / CVV

Card type Visa Mastercard

Signed

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© Confederation of Australian Motor Sport Ltd. trading as Motorsport Australia
Licence Application/Renewal
Circuit, Rally, Off Road - 2024

Health Statement (must be completed by all applicants)

Please indicate if you have any significant or recurrent problems with any of the following:

Anxiety/depression or other mental health condition Headaches/migraine/head injury

Diabetes Heart disease

Any medical condition that may negatively impact your capacity to

Epilepsy
safely participate in motorsport activities

Fits/fainting/dizziness Please specify

If you have ticked any of the above, you are required to provide additional information relating to your condition.
For more information go to: motorsport.org.au/membership/medical or contact Member Services on 1300 883 959

Please indicate if you are affected by any of the following conditions:

Do you suffer from any allergies? Please specify

Hearing loss or deafness

Do you wear glasses or contact lenses when driving?

If you have ticked any of the above, you are not required to provide any additional information relating to these conditions and can
continue with your application.

PROVIDE DETAILS OF ANY OTHER MEDICAL CONDITION OR DISABILITY WHICH COULD RESTRICT YOU GENERALLY
(eg. Knee injury, broken foot, broken arm)

Motorsport Australia may request further information from you or your doctor before accepting your application for a licence.
Depending on your medical history or status, Motorsport Australia may not be able to issue you with a licence.
Please note that you are under a continuing obligation to inform Motorsport Australia of any medical matter that may or could
impact your physical or mental capacity to participate in Motorsport Activities.

Crashtag Consent

I consent to any medical practitioner, first aid provider or allied health professional providing first aid or medical treatment to me at or in
relation to a motorsport event entering my information into Crashtag or accessing information about me stored in Crashtag
Visit crashtag.com for more information about the motorsport incident reporting application

Fit and Proper Person

I acknowledge and agree that it is a fundamental condition of issue of this licence and its continuing validity that I:
1. have advised Motorsport Australia in writing of any act, omission, fact or circumstance which may affect my ability to
be and remain a fit and proper person to hold this licence and exercise the duties and privileges that relate to it;
2. have advised Motorsport Australia in writing if I have been found guilty of or charged with any:
a. serious indictable criminal offence; or
b. sexual offence, (unless this is a ‘spent’ or ‘annulled’1 conviction); and
3. undertake to advise Motorsport Australia immediately in writing upon any court of competent
jurisdiction making any such finding, or upon being charged with any such offence.
I acknowledge and agree that Motorsport Australia may, in its absolute discretion (subject to this clause) refuse to issue, suspend
or withdraw this licence at any time should Motorsport Australia reasonably form the view that I may not be, or am not, a fit and
proper person to be granted or hold this licence and/or exercise any of the duties and/or privileges that arise from, or relate,
to it, however I understand that before a licence is refused, suspended or withdrawn by Motorsport Australia I will be afforded
the opportunity to address the Motorsport Australia Board in writing on the proposed refusal, suspension or withdrawal.
1
As determined by the Crimes Act 1914 (Cth), Criminal Records Act 1991 (NSW), Criminal Law (Rehabilitation of Offenders) Act 1986 (Qld), Spent Convictions Act 2000 (ACT), Criminal
Records (Spent Convictions) Act 1992 (NT), Spent Convictions Act 1988 (WA) and/or the Annulled Convictions Act 2003 (Tas) (including their successors and replacements.)

All Circuit, Rally and Superkart Licence applicants must

SIGNATURE SIGN HERE complete the Motorsport Australia Medical Examination on
Pages 6-7.

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© Confederation of Australian Motor Sport Ltd. trading as Motorsport Australia
Licence Application/Renewal
Circuit, Rally, Off Road - 2024

Risk Warning and Disclaimer

Motorsport Activities are inherently dangerous recreational activities and there is significant risk of injury, disability or death.
If you do not wish to be exposed to such risks, then you should not participate in the Motorsport Activities.
Acknowledgement of Risks
I acknowledge that the risks associated with attending or participating in Motorsport Activities include but are not limited to the risk that I may suffer harm as a result of:
● motor vehicles (or parts of them) colliding with other motor vehicles or persons or property;
● other participants acting dangerously or with lack of skills;
● high levels of noise exposure;
● acts of violence and other harmful acts (whether intentional or inadvertent) committed by persons attending or participating in the event; and
● the failure or unsuitability of facilities (including grand-stands, fences and guard rails) to ensure my safety.
Exclusion of Liability, Release and Indemnity
In exchange for being able to attend or participate in the Motorsport Activities, I will and agree to:
● to release Motorsport Australia and the Entities to the extent that any or all of them are providing Recreational Services from all liability for:
● my death;
● any physical or mental injury (including the aggravation, acceleration or recurrence of such an injury);
● the contraction, aggravation or acceleration of a disease including but not only COVID-19;
● the coming into existence, the aggravation, acceleration or recurrence of any other condition, circumstance, occurrence, activity, form of behaviour, course of conduct or
state of affairs:
● that is or may be harmful or disadvantageous to me or the community; or
● that may result in harm or disadvantage to me or the community,
● any claim for any costs and expenses I may incur as a consequence of any of the above;
arising from my participation in or attendance at the Motorsport Activities;
● to indemnify and hold harmless and keep indemnified Motorsport Australia and the Entities to the maximum extent permitted by law in respect of any Claim by any person; and
● to attend at or participate in the Motorsport Activities at my own risk.
I understand that:
● nothing in this document excludes, restricts or modifies any rights that I may have as a result of significant personal injury that is caused by the Reckless Conduct of Motorsport Australia
and the Entities as the supplier of the Motorsport Activities and Recreational Services;
● nothing in this document prevents Motorsport Australia and the Entities from relying on any laws (including statute and common law) that limit or preclude their liability;
● nothing in this document excludes any term or guarantee which under statute cannot be excluded, however the liability of Motorsport Australia and the Entities is limited to the minimum
liability allowable by law;
● nothing in this document precludes me from making a claim under a Motorsport Australia insurance policy where I am expressly entitled to make a claim under that insurance policy; and
● Motorsport Australia has arranged for limited personal injury insurance coverage which may provide me with some protection for loss, damage or injury that I may suffer during my
participation in the Motorsport Activities. I acknowledge and accept that the insurance taken out by Motorsport Australia may not provide me with full indemnity for loss, damage or
injury that I may suffer during my participation in the Motorsport Activities, and that I may have to pay the excess if a Claim is made under an insurance policy on my behalf. I agree that
my own insurance arrangements are ultimately my responsibility and I will arrange any additional coverage at my expense after taking into account Motorsport Australia’s insurance
arrangements, this document and my own circumstances.
Where Motorsport Activities are held in the following jurisdictions, I acknowledge that I have also read and accept the following warnings:
Under Australian Government Consumer Law (which is part of the Competition and Consumer Act 2010 (Commonwealth)), several guarantees are implied into contracts for the supply
of certain goods and services. I agree that the application of all or any of the provisions of Subdivision B of Division 1 of Part 3-2 of Australian Consumer Law (i.e. guarantees relating to
the supply of services), the exercise of rights conferred by those provisions, and any liability of Motorsport Australia and the Entities for a failure to comply with any such guarantees, are
excluded. However, such exclusion is limited to liability for:
● death, physical or mental injury (including aggravation, acceleration or recurrence of such an injury of the individual);
● contraction, aggravation or acceleration of a disease of an individual; or
● the coming into existence, the aggravation, acceleration or recurrence of any other condition, circumstance, occurrence, activity, form of behaviour, course of conduct or state of affairs
in relation to an individual that is or may be harmful or disadvantageous to the individual or the community, or that may result in harm or disadvantage to the individual or the community.
This exclusion does not apply to significant personal injury suffered by me as a result of the reckless conduct of Motorsport Australia and the Entities.
Warning Applicable in Relation to Motorsport Activities Held in Victoria
Warning Under The Australian Consumer Law and Fair Trading Act 2012:
Under The Australian Consumer Law (Victoria), several statutory guarantees apply to the supply of certain goods and services. These guarantees mean that the supplier named on this
form is required to ensure that the recreational services it supplies to me:
● are rendered with due care and skill;
● are reasonably fit for any purpose which I either expressly or by implication, make known to the supplier; and
● might reasonably be expected to achieve any result I have made known to the supplier.
Under section 22 of the Australian Consumer Law and Fair Trading Act 2012 (Vic), the supplier is entitled to ask me to agree that these conditions do not apply to me. I understand that
if I sign this form, I am agreeing that any rights to sue the supplier under the Australian Consumer Law and Fair Trading Act 2012 if I am killed or injured because the services were not in
accordance with these guarantees, are excluded, restricted or modified in the way set out in this form.
Note: I note that the change to my rights, as set out in this form, does not apply if my death or injury is due to gross negligence on the supplier’s part.
“Gross negligence” in relation to an act or omission, means doing the act or omitting to do an act with reckless disregard, with or without consciousness, for the consequences of the act or
omission. See regulation 5 of the Australian Consumer Law and Fair Trading Regulations 2012 and section 22(3)(b) of the Australian Consumer Law and Fair Trading Act 2012.
Warning Applicable in Relation to Motorsport Activities Held in South Australia
Under sections 60 and 61 of The Australian Consumer Law (SA), if a person in trade or commerce supplies me with services (including recreational services), there is a statutory guarantee
that those services:
● will be rendered with due care and skill; and
● any product resulting from those services, will be reasonably fit for the purpose for which the services are being acquired (as long as that purpose is made known to the supplier); and
● any product resulting from those services, will be of such a nature, and quality, state or condition, that they might reasonably be expected to achieve the result that the consumer wishes
to achieve, (as long as that wish is made known to the supplier or a person with whom negotiations have been conducted in relation to the acquisition of the services.
Excluding, Restricting or Modifying My Rights:
Under section 42 of the Fair Trading Act 1987 (SA), the supplier of recreational services is entitled to ask me to agree to exclude, restrict or modify their liability for any personal injury
suffered by me or another person for whom, or on whose behalf, I am acquiring the services (a third party consumer). If I sign this form, I am agreeing to exclude, restrict or modify the
supplier’s liability with the result that compensation may not be payable if I or the third party consumer suffer personal injury.
Important:
I do not have to agree to exclude, restrict or modify my rights by signing this form. The supplier may refuse to provide me with the services if I do not agree to exclude, restrict or modify my
rights by signing this form. Even if I sign this form, I may still have further legal rights against the supplier. A child under the age of 18 cannot legally agree to exclude, restrict or modify their
rights. A parent or guardian of a child who acquires recreational services for the child cannot legally agree to exclude, restrict or modify the child’s rights.
Agreement to exclude, restrict or modify my rights:
I agree that the liability of Motorsport Australia and the Entities for any death or personal injury that may result from the supply of the recreational services that may be suffered by me (or a
person for whom or on whose behalf I am acquiring the services) is excluded. Further information about these rights can be found at www.cbs.sa.gov.au
Definitions:
a. “Claim” means and includes any action, suit, proceeding, claim, demand or cause of action however arising including but not limited to negligence, BUT does NOT include a claim under
a Motorsport Australia insurance policy by any person expressly entitled to make a claim under that insurance policy;
b. “Entities” means event and competition organisers/promoters/managers, land and track owners/managers/administrators/lessees, Motorsport Australia affiliated clubs, state and
territory governments and insureds listed in Motorsport Australia’s public/product/professional indemnity insurance policies and each of their related bodies corporate (including their
related bodies corporate) and each of their organs and agencies, officers/president/directors/executives, employees, servants, agents, partners, providers, members, competitors,
drivers, co-drivers, navigators, officials, crew members, service crew, delegates, licence holders, representatives, commissions, committees, advisers, trustees, councils, panels,
shareholders, volunteers, officials, appointees, delegated bodies and sponsors;
c. “Motorsport Activities” means any motorsport activities or Recreational Services which are permitted or approved which Motorsport Australia regulates or administers or otherwise are
under the responsibility / control of Motorsport Australia;
d. “Motorsport Australia” means the Confederation of Australia Motor Sport Ltd. trading as Motorsport Australia;
e. “Reckless Conduct” means conduct where the supplier of the recreational services is aware, or should reasonably have been aware, of a significant risk that the conduct could result in
personal injury to another person and engages in the conduct despite the risk and without adequate justification;
f. “Recreational Services” means (unless otherwise defined in this document) services that consist of participation in:
a. a sporting activity; or
b. a similar leisure time pursuit or any other activity that:
i. involves a significant degree of physical exertion or physical risk; and
ii. is undertaken for the purposes of recreation, enjoyment or leisure.

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motorsport.org.au
© Confederation of Australian Motor Sport Ltd. trading as Motorsport Australia
Licence Application/Renewal
Circuit, Rally, Off Road - 2024

Respect Code

Motorsport Australia is committed to providing a fair, safe and socially responsible motorsport for all members of the Motorsport Community.
In participating in a Motorsport Australia event, in any capacity, a standard of behaviour is expected in accordance with our shared values.
We value each other, our differences, our opinions and we commit:
• To treat all people with dignity, respect and fairness, regardless of age, disability, sex, race, culture or ethnicity, religious beliefs, social
background, sexual orientation or gender identity.
• To recognise that people of all backgrounds can offer a valuable contribution to motorsport and support Motorsport Australia’s
commitment to be inclusive and welcome all members of the Australian community into our sport.
• To be ethical, fair and honest, and always act with integrity.
• To be responsible for the physical and psychological safety and welfare of all people involved in motorsport.
I understand that my role in motorsport, whether it be as a competitor, official, volunteer, crew or spectator, contributes to the image of
motorsport as a welcoming, friendly and fair sport. I understand that breaching these obligations may result in disciplinary action.

Declaration (must be completed by all applicants)

ANY APPLICANT MAKING A FALSE DECLARATION IS LIABLE TO REFUSAL AND CANCELLATION OF INSURANCE COVER
I accept the conditions of, and acknowledge the risks arising from, attending or participating in Motorsport Activities being provided by
Motorsport Australia and the Entities. I agree to be bound by the rules, regulations and policies of Motorsport Australia at all times as a
condition of participating in this activity. The information I have entered into this form is true and correct and I will advise Motorsport Australia
immediately if any of the information I have given is no longer true and correct. I have read, understood, acknowledge and agree to the above
including the exclusion of statutory guarantees, warning, assumption of risk, release and indemnity.

SIGNATURE DATE ­— —
­

Parent/Guardian Consent (must be completed for all applicants under 18 years of age)

I, of

am the parent/ guardian (tick applicable) of the above-named (‘Minor’) who is under 18 of age. I have read this document
and understand its contents, including the exclusion of statutory guarantees, warning, assumption of risk, release and indemnity, and
have explained the contents to the Minor. I consent to the Minor attending or participating in the event at their own risk.

SIGNATURE DATE ­— —
­

Your Privacy
Motorsport Australia requires the above information to assess your suitability for Motorsport Activities. The information provided by you
may be used and disclosed to others by Motorsport Australia for the purposes of Motorsport Australia’s business. Motorsport Australia
may not be able to permit you to undertake the Motorsport Activities if you do not provide all of the information requested above. Full
details of Motorsport Australia’s Privacy Policy (including how you can access and correct your personal information and make a complaint)
are available at Motorsport Australia’s website (motorsport.org.au). In the event that you suffer from any injury, sickness or death during
any Motorsport Activities you consent to the release by health services of your personal health information to an authorised representative
of Motorsport Australia who may use it in the preparation and release of accident or incident information and reports to interested parties
for the purposes of accident investigation, accident prevention and safety activities or for the purposes of processing insurance claims.
Motorsport Australia and its partners may send you direct marketing materials from time to time. This is in addition to
relevant information which Motorsport Australia may send to you as part of Motorsport Australia’s services.

Please tick this box if you DO NOT want to receive direct marketing materials from Motorsport Australia or its partners

Please return to:

Motorsport Australia
Mail: PO Box 172 Canterbury LPO, VIC 3126
Email: [email protected]

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motorsport.org.au
© Confederation of Australian Motor Sport Ltd. trading as Motorsport Australia
Medical Examination Record
(must be completed by a Medical Practitioner registered to practice medicine in Australia)

Applicable to Circuit, Rally and Superkart Licence Holders only

(Rally licence holders required to complete Medical Examination Record as per changes implimented 1 August 2023)
If significant abnormalities are found, please obtain specialist opinion or pathology as indicated and return
with this form. If doubtful, refer to the Motorsport Australia Member Hotline — 1300 883 959
This medical is valid for 3 months from the date of examiners signature

Notes: 1. Photo ID required.

2. Please ensure a thorough understanding of the medical standards is acquired prior to completing the examination.
3. Please attach any Specialists’ reports or any pathology or radiology results relevant to this application.
4. If the applicant wears contact lenses, please attach to this report a certificate from the Ophthalmic Practitioner who fitted them, stating their
(i) stability, (ii) duration of daily use and (iii) condition.
5. BMI (i) The Body Mass Index is weight (in kilograms) divided by the square of the height (in metres).
(ii) 20-25 Acceptable – normal range 25-30 Health risk area 30-35 Obese 35-40 Morbidly obese
6. The ‘normal’ answer to each question below is ‘NO’. In respect of each ‘YES’ response, further details should be provided in Examiner’s Comments.

Motorsport Australia Licence

Applicant’s name Member/licence no. level/type
(if applicable) (if applicable)

General Malignancy
Any current malignancy of any system, other
Height(m) Yes No
than non-melanoma skin cancer?
Weight(kg) Central Nervous System
Body Mass Index (BMI) weight/(height)2 Abnormality(s) of cranial nerves/limb tone/
Yes No
power/coordination/tendon/plantar response?
Cardiovascular System Sensory impairment? Yes No
Note the concussion protocol in Motorsport Australia Medical Standards
Pulse rate Max. 100 (motorsport.org.au/medical), specifically point 4.6c

Rhythm abnormal? Yes No ENT System

Blood pressure Max. 150/90 (mmHg) / Evidence of past or present vestibular
Yes No
disturbance, including intermittent conditions?
Peripheral pulses abnormal? Yes No Abnormality(s) of the ENT system? Yes No
Familial hypercholesterolaemia? Yes No
Visual System
Evidence of past or present
ischaemic heart disease? Yes No
Abnormality(s) of the eyes? Yes No
Total Cholesterol  (mg/dL)
Contact lenses? Yes No
If Yes, Certificate of Ophthalmic Prac. required
Fasting Lipids LDL (mg/dL)
Refractive surgery? Yes No
HDL
(mg/dL) If Yes, Certificate of Ophthalmic Prac. required

Fasting Glucose  (mg/dL) Visual Acuity

Test each eye separately with letter chart at 6 m
Respiratory System
Record in metric Snellen notation. e.g. 6/9
Record number of errors made in smallest line read. e.g. 6/9 -3 RE LE
Abnormality(s) of the respiratory system? Yes No
Unaided (without contact lenses or spectacles) 6/ 6/
Smoking status Never smoked
Aided (with contact lenses or spectacles) 6/ 6/
Previously smoked

Currently smokes Eye Movement

Evidence of past or present diplopia?
Abdomen If Yes, applicant must complete a full eyesight Yes No
examination and full assessment of their ocular mobility
Abnormality(s) of the abdomen? Yes No
Visual Fields
Urinary System Complete a confrontation test for each eye separately

Does the urine contain: Protein Ocular or general medical history that
Yes No
suggests the possibility of visual field loss?
Glucose Confrontation test suggest a loss of visual
Yes No
fields in either eye?
Other abnormality(s)?
Visual Fields
Locomotor System
Test with Ishihara
Physical deformity/amputation or use More than three (3) errors is a FAIL indicating abnormal colour vision.
Yes No
of orthopaedic appliance? (For first licence only, not required for licence renewal)
Is there any impaired functional use,
Yes No Ishihara test failed? Yes No
either from above or otherwise?
Impaired use/movement of any If Yes, the applicant will likely need to be referred for a full
limb/joint/hand/foot which might Yes No eyesight examination by an optometrist or an ophthalmologist)
compromise control of a motor vehicle? or
The further assessment of colour vision shall be complete via the
Note the requirements of point 2.1 of the Motorsport Australia Medical Standards Famsworth D15 test, to test the severity of the colour vision defect.
(motorsport.org.au/medical) in regards to physical disability Any individual who fails the Famsworth D15 test by making two or more
diamettrical crossings is assessed as UNFIT.
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© Confederation of Australian Motor Sport Ltd. trading as Motorsport Australia
Medical Examination Record
(must be completed by a Medical Practitioner registered to practice medicine in Australia)

ECG
A resting ECG is required with all Medical Examinations.
A copy of the ECG chart/report must be submitted as part of the medical examination form.
Note the requirements of point 1.5 of the Motorsport Australia Medical Standards (motorsport.org.au/medical) in regards to Mandatory Frequency of Examination

Other comments:
ECG Results: /

ECG abnormal? Yes No

If abnormal, date completed: ­— ­—

Examiner’s Comments

1 On history:

2 Are there any unfavourable traits in applicant’s personality, revealed by history, appearance or behaviour?

3 Has the applicant been prescribed drugs which are in contravention of the Motorsport Australia Anti-Doping policy,
or inhaled asthma medications? If so, please advise drug, dosage and reason:

4 In your opinion, is the applicant fit to participate in motorsport? Yes No Further assessment

Statement by Registered General Practitioner

The applicant was examined on: ­— ­— Examiner’s signature

Applicant’s photo ID sighted? YES NO

Are you the applicant’s normal GP? YES NO

Name of medical examiner: MEDICAL

Address of medical examiner: EXAMINERS
Suburb: State: Postcode:
STAMP

This medical is only valid for 3 months from the date of examiners signature

Please return to: Motorsport Australia

Mail: PO Box 172 Canterbury LPO, VIC 3126
Email: [email protected]

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motorsport.org.au
© Confederation of Australian Motor Sport Ltd. trading as Motorsport Australia