2024 Registration Form

Given Name *

Last Name *

House Number and Street *

District

Town or City

County

Post Code *

Date of Birth

Occupation

Enter your email address *

Mobile or Home Phone Number *

MSUK Competition License *

MSUK License Number *

Vehicle Details

Make of Car

Type of Vehicle

Year of Manufacture

Capacity - CC

Engine Type (Turbo Charge, Rotary, etc.)

M H C Class Entered *

Parent Club

Parent Club *

Club Membership Number *

Payment Details

The 2024 Fees for the Midland Hillclimb Championship are as follows:-
Championship Entry and Midland Hillclimb Member ship - £97.50
Championship Entry Only - £90

Please indicate what Fees you will be paying *

Method of Fee Payment *

If you are paying by cheque or postal order please make them payable to "Midland Hillclimb Championship (2017) Limited".

If paying by cheque or postal order please complete these and send to:
Bill Pardoe
MHC Coordinator
15 The Hawthorns,
Kidderminster,
DY10 3DH
If it is not obvious please write the drivers name on the back of the cheque/PO.

Next of Kin Information

Name of Person

Phone Number

Relationship to the Above Driver

Confirmation Statement *

I confirm that, I, the named driver above have had the ability to download the Supplementary Regulations(SRs) for the 2024 Midland Hillclimb Championship and have read the said SRs and undertake to comply with them, the General Regulations of Motorsport UK and any Bulletins issued by Midland Hillclimb Championship. I further declare that all information given on this form is factual and I am eligible to compete in the events that form the championship.

Date of Submission *

GDPR - Statement *

The details you have submitted above will be emailed to the coordinator(s) and may be held on a computer system under the control of the said co-ordinator(s) or website administrator.

Please note that all information held will not be passed to third parties and will only be used in the administration of the championship.

Parental Consent

Where the registrant is under the age of 18 years, the following must be completed by the Parent or Legal Guardian.

Name of Parent / Legal Guardian

Address

Phone Number

Relationship to the above driver

reCAPTCHA *