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    Online Entry: 2018 4 & Rotary Nationals | Track Only

    Please read through the driver information on our website before completing this form.

    We recommend using Google Chrome or Firefox to complete this form.

    Our Track day is intended for vehicles who can participate in most sessions. If you're only here for one session (e.g. only drifting), a regular trackday may be better suited for you.

    ENTRANT DETAILS

    First Name:(*)
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    Surname:(*)
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    Address:(*)
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    Town:
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    Telephone: (landline)
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    Telephone: (mobile)(*)
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    Email Address:(*)
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    Age:(*)
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    Occupation:
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    Drivers Licence #:
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    VEHICLE DETAILS

    Please upload an image of your car for our records and to use in our gallery of competitors.
    Only photos submitted with your entry form will be posted in our competitor gallery. If you submit your photo via facebook or email, it may not be posted.
    Upload a picture of your car(*)
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    Is your Vehicle Registered?(*)
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    Do you have a current WOF?(*)
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    Number Plate:(*)
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    Make:(*)
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    Model:(*)
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    Year:(*)
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    Colour:(*)
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    Capacity:(*)
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    Engine Type:(*)
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    Number of Cyl/Rotors:(*)
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    ENTRY DETAILS

    Entry Fee:

    Track Entry

    Early Bird Entry: $120 (Valid until 30 Nov)
    Online Entry: $170 (Valid until 24 Jan)
    Late Entry: $200 (On the day only if not sold out)

    VIP Track Entry (+$60) gets you priority entry out onto the track, as well as VIP Safety Check and Registration to minimise queues.

    Entry fee covers 1 driver and 1 vehicle for Sunday Only.

    A LATE ENTRY FEE OF $50 WILL BE ADDED TO ALL TRACK ENTRIES PLACED AFTER 1ST DECEMBER
    Entry Desired:(*)
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    VIP Track Entry Upgrade(*)
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    Total
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    Are you insured with NAC? If so, would you like to be sent info on how you can be insured on the track?(*)
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    Free Tshirt size:(*)
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    Have won at our event before?(*)
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    If so can you please tell us what ones
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    We appreciate your entry and aspire to provide a friendly, exciting and safe experience.

    Indemnity: We advise that all activities do carry a degree of risk and that by participating in the activity provided by Pukekohe Park Raceway and Premier Events, you are expressly assuming those risks personally and are releasing Pukekohe Park Raceway, Premier Events and land owners and their officials, representatives and agents (hereinafter known as the promoter) from any liability, claims, losses, damages or expenses caused by any event including, but not limited to:
    - personal injury or death – acts which may be constructed as negligent or accidental
    - property loss or damage – any other loss, damage, suffering, emotional or nervous disorder.

    In participating in the activity I agree to the conditions set out as above and consent to the conditions in clauses 2a to 2d below, and 3 and 4:
    (a) I agree that my successors, executors, administrators and next of kin are bound by these terms and conditions.
    (b) I agree not to commence any litigation or proceedings in relation to the risks and perils set out in 1 above and to indemnify the Promoter against any such claims.
    (c) I confirm that I am physically fit and suffer no medical conditions that could put me or another person at risk during this activity.
    (d) I consent to receive medical treatment in the case of injury, accident or illness during that activity and to indemnify the Promoter against any claims in respect of this treatment.
    3. I agree that any films, sound, video or other recordings of or during the activity can be used by the promoter at it's complete discretion without prior approval.
    4. Refunds are entirely at the discretion of the promoter. No express or implied warranty of safety shall result from scrutineering checks.

    Safety checks are intended to assist the competitor in his/her own safety checks and are in no way a guarantee against injury or death to a spectator or the participants. We will not share, sell, or rent individual personal information with anyone without your advance permission or unless ordered by a court of law. Information submitted to us is only available to employees managing this information for purposes of contacting you or sending you emails based on your request for information and to contracted service providers for purposes of providing services relating to our communications with you.

    Entry fee will only be refundable if entry is withdrawn via email prior to 13th January and an administration fee of $30 will be retained.

    Any change of vehicle or driver details will occur a $30 administration fee.
    Acceptance Of Terms(*)
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    BILLING DETAILS

    Card Type:(*)
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    Direct Debit:
    Payments are to be made to "4 and Rotary Promotions"
    Account Number: 03-0179-0294140-002

    Please use your Number Plate as a Reference and Last Name as the Particulars.

    Payments are to be made within two working days from submitting this form.
    Name On Card:
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    Card Number: (no spaces)
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    Expiry ( MM/YY ):
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    Submit Entry
    After clicking the SUBMIT button your entry will be processed. This usually takes 1-3 working days.

    Once we process and validate your entry and credit card details we will then confirm your entry via email and issue you with your registration number.

    If you still see your entry form please check for errors in red.