Club Membership

Club Membership Selection

**N.B. All fields marked with an * are mandatory and must be completed for successful submission of the form!**

Membership Types Available

Instructions

Please select the membership type that best suits you.

Membership Type*

Senior $50 Single Adult

Family $100 2 adults/up to 3 Under 18's

Junior $25 Under 18s

Senior Single Adult plus Super Stocker Registration $100

Family 2 adults/up to 3 Under 18’s plus Super Stocker Registration $150

Primary Club Member Details

**N.B. All fields marked with an * are mandatory and must be completed for successful submission of the form!**

First Name*

Enter here...

Last Name*

Enter here...

Date of Birth*

Select Date ×

Contact Email*

Street Address:*

Street No. and Name:

Town/Suburb

Country

State:

Postal Code

Home Phone:

Enter here...

Mobile Phone:*

Enter here...

Do you hold a current Speedway Australia License?*

Yes

Do you hold a current Working with Children card?*

Yes

Do you own a registrable speedway race car?*

Yes

License Details

License Type:

Enter here...

License Number:

Enter here...

License Expiry:

Select Date ×

Blue Card Details

Blue Card Number:

Enter here...

Blue Card Expiry:

Select Date ×

Adult Member 2

**N.B. All fields marked with an * are mandatory and must be completed for successful submission of the form!**

First Name*

Enter here...

Last Name*

Enter here...

Date of Birth*

Select Date ×

Contact Email:*

Type your email here...

Street Address:*

Street No. and Name:

Town/Suburb

Country

State:

Postal Code

Home Phone:

Enter here...

Mobile Phone:*

Enter here...

Children Under 18

**N.B. All fields marked with an * are mandatory and must be completed for successful submission of the form!**

Family Members
up to 3 children under 18

Race Car Details

**N.B. All fields marked with an * are mandatory and must be completed for successful submission of the form!**

Race car Details

Make & Model

Enter here...

Car Number:

Enter here...

Race Division

Enter here...

RSCC Super Stockers Registration

**N.B. All fields marked with an * are mandatory and must be completed for successful submission of the form!**

RSCC Super Stocker Car Details

Please Note:

If you require a vehicle to be daylighted please contact Laurie Storer or Alan Stock to arrange this.

If you do not yet have a racing number issued by the RSCC please contact Laurie Storer to arrange this

Laurie Storer – 0428 436 158 – lauriestorer4x@bigpond.com
Alan Stock – 040 815 7434 – alan.stock.68@gmail.com

The above details will be emailed to you on completion of this application

Car Make & Model*

To arrange your daylight inspection please see the contact details above.

Enter Here

Car Number:

If you do not yet have a racing number issued by the RSCC please leave this BLANK.

Enter Here

Agreement & Payment

**N.B. All fields marked with an * are mandatory and must be completed for successful submission of the form!**

Data Collection & Storage

Your Personal Data

Your personal data is required under law and will be stored securely by our club. Your data will NOT be sold, swapped or shared by us to any unauthorised entities!*

I give permission for the storage of my personal data in accordance with the Privacy Policy.

Electronic Signature Agreement

I hereby apply for membership of the Rockhampton Saloon Car Club. I agree to abide by the Rockhampton Saloon Car Club Constitution and the Australian Speedway Race Rules, Regulations and Specifications. I give permission for the club to use photos of myself and race car for promotional purposes.*

By selecting this, you are signing this application electronically

Online Secure Payment

Payment Amount

Payment Method*

Credit Card/Debit

Enter Card Details*

we do not store any information you provide

By submitting this form, you hereby agree to accept our Terms & Conditions. Your IP address 51.222.253.17 will be stored in our database.

Complete the form below to be a Club Member

Rockhampton Saloon Car Club Inc.

2023-24 Membership Form

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Club Membership Selection

N.B. All fields marked with an * are mandatory and must be completed for successful submission of the form!

Membership Types Available

Primary Club Member Details

N.B. All fields marked with an * are mandatory and must be completed for successful submission of the form!

License Details

Blue Card Details

Adult Member 2

N.B. All fields marked with an * are mandatory and must be completed for successful submission of the form!

Children Under 18

N.B. All fields marked with an * are mandatory and must be completed for successful submission of the form!

Family Members up to 3 children under 18

Race Car Details

N.B. All fields marked with an * are mandatory and must be completed for successful submission of the form!

Race car Details

RSCC Super Stockers Registration

N.B. All fields marked with an * are mandatory and must be completed for successful submission of the form!

RSCC Super Stocker Car Details

Agreement & Payment

N.B. All fields marked with an * are mandatory and must be completed for successful submission of the form!Data Collection & Storage

Your Personal Data

Electronic Signature Agreement

Online Secure Payment

Your application has been submitted

Rockhampton Saloon Car Club Inc.

Postal Address

Contact Number

Contact Email

Website

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Rockhampton Saloon Car Club

Privacy

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**N.B. All fields marked with an * are mandatory and must be completed for successful submission of the form!**

**N.B. All fields marked with an * are mandatory and must be completed for successful submission of the form!**

**N.B. All fields marked with an * are mandatory and must be completed for successful submission of the form!**

**N.B. All fields marked with an * are mandatory and must be completed for successful submission of the form!**

Family Members
up to 3 children under 18

**N.B. All fields marked with an * are mandatory and must be completed for successful submission of the form!**

**N.B. All fields marked with an * are mandatory and must be completed for successful submission of the form!**

**N.B. All fields marked with an * are mandatory and must be completed for successful submission of the form!**

Data Collection & Storage

Rockhampton
Saloon Car Club