2016 Track Licence application form. for Race, Speed and Kart venues

Transcription

1 2016 Track Licence application form for Race, Speed and Kart venues

2 Prior to application being made for an Organising Permit, the appropriate Track Licence must have been issued for the specific Venue to be used. The Track Licence must be in place for a minimum of 60 days prior to an International Event, or 30 days prior to a National Event. Venue: Please write clearly in BLOCK CAPITALS Club/Organisation details (to whom the Track Licence will be issued and dispatched) Club/Organisation: Contact name: Address: Telephone number: address: Previous licence details Number & date of issue of most recent Track Licence: Date of most recent MSA venue inspection: Fees (VAT inclusive) Date of event (only for a single-day event): Race: Speed: Kart: Race International:* 6470 Speed International: 1000 Kart International:* 825 Race National A: 3250 Speed National A: 835 Kart National A: 790 * plus FIA fee Speed National B: 590 Kart National B: 580 Speed Clubman: 590 * plus CIK fee Notes: a) For venues with no more than one single day meeting per year, half of the above fee is charged. (Not applicable for International or Truck meetings) b) Where a number of categories are covered, only the highest value fee is payable Office use only: Passed to Sales: Chq/BACS: Amount: Licence Grade: Page 1 of 6

3 Venue details Venue address: Telephone number: address: Website: Nearest town (& distance): Location of the venue, with reference to major roads and towns/villages etc.: Postcode for use with sat-nav : Course details Direction of running:* Clockwise / Anti-clockwise * Indicate as applicable Name Length (km) Width (m) Discipline* Grade* R DR International Circuit 1: Circuit 2: Circuit 3: Circuit 4: S K National A HC T National B RX Clubman R DR International S K National A HC T National B RX Clubman R DR International S K National A HC T National B RX Clubman R DR International S K National A HC T National B RX Clubman * Clearly tick as applicable R = Car Race; S = Sprints; HC = Hillclimb; RX = Rallycross; DR = Drag Race; K = Kart Race; T = Truck Race Page 2 of 6

4 Start & finish line position(s) (including method of marking): Scrutineering area (location, facilities, Parc Fermé etc.): Noise testing area location: Rescue and medical services Number of ambulances: Number of medical staff: Number and location of Rescue Unit(s) (race/speed/rallycross): Location of ambulance(s): Location of first-aid headquarters/ medical staff: Special features of course (type of surface, varying width etc.): Location of nearest outside telephone and number: Address and telephone of nearest hospital available to receive casualties: Race circuits only: Medical Committee members: Chief Medical Officer: Marshals & recovery * Indicate as applicable Number and location of breakdown vehicles: Number of Observers posts: Number of additional posts: Page 3 of 6

5 Fire safety Type(s) of extinguishers used: Date(s) of certification: No. of extinguishers around the course: No. of extinguishers in Medical Centre: No. of extinguishers in the paddock: No. of extinguishers in the pits area: No. of extinguishers in Scrutineering bay: Details of fire tenders and crew, when required (see (E)7.4) and location(s): Vehicle 1 location: Equipment: Vehicle 2 location: Equipment: Vehicle 3 location: Equipment: Extinguisher type: Number: Extinguisher type: Number: Extinguisher type: Number: Other: Communication systems Type of communication system(s) available to officials around the course (e.g. telephone, radio): Details of any CCTV system(s) under the control of the Clerk of Course: Enclosed documents: Land owners agreement: Yes / No/ N/A * Venue plan:^ Course plan (A4 size, suitable for incorporating into the Track Licence):^^ Major incident plan: Minutes of the last Medical Committee meeting (Race circuits only): Yes / No/ N/A * * Indicate as applicable ^ A scale plan of the venue, in as much detail as possible, including all relevant key information, such as scrutineering, noise testing, medical centre, officials enclosures etc. ^^ Detailed course plan showing all marshals/observers posts, safety vehicle locations, start/finish line(s), pit/paddock entry & exit. Page 4 of 6

6 Declaration I enclose a cheque / have made electronic (BACS) transfer * in the sum of. Cheques payable to Motor Sports Association, or see Appendix 1 for bank details. (NB. all higher grade licences are valid for lower grades of events of the same discipline). * delete as applicable I confirm that the venue owners have provided written agreement as required by (E)1.1. (Only applicable if the Track Licence applicant is not the venue owner). I declare that the photographic record enclosed is an accurate representation of the course to which this application relates. Date photographs taken:. I declare that the track plan dated enclosed herewith is correct and no changes or modifications will be made unless agreed by the MSA. (See requirements set out in (E) ). I declare that all the work specified in MSA venue inspection reports issued since 31st December 2003 has been completed and to a satisfactory standard. I declare that for MSA authorised events, the venue will be maintained and prepared in accordance with the criteria agreed with the MSA. I declare that I know no reason why the Track Licence applied for should not be issued to me or the organisation that I represent, for the calendar year (or part of year) for which the Licence is to be issued. I declare that a major incident plan has been drawn up for this venue that it is reviewed from time to time and that appropriate staff and officials are familiar with this plan. In consideration of a Track Licence being issued, I undertake to abide by the conditions of issue specified by The Royal Automobile Club Motor Sports Association Ltd, all of which I am acquainted with and understand. I understand and accept that an MSA Track Licence is only valid for such periods as when an MSA Organising Permit is in force and only relates to the MSA activity authorised by that Organising Permit. I acknowledge that: o o o The MSA does not assume any responsibility in relation to activities not covered by an MSA Organising Permit and that it remains the responsibility of the venue owner and/or operator to ensure that all safety precautions at the venue are appropriate for such activities and to seek independent advice as necessary in relation to them. The MSA Track Licence, any related correspondence from the MSA or advice given by the MSA, its servants or agents only relates to MSA authorised activities and should not be relied upon for any other purpose. It is a condition precedent to the granting of the Track Licence hereby applied for that the venue owner and/or operator shall fully and completely indemnify and save harmless MSA in respect of all claims by any person whatsoever for injury to person or property caused by or in connection with or arising out of the use of the venue for any purpose not authorised by an MSA Organising Permit whether such claims arise out of negligence on the part of the MSA, its servants or agents or otherwise howsoever and in respect of all costs and charges in connection herewith whether arising under statute or common law. Signed: Name: Date: Please return completed forms with correct payment to: Motor Sports Association, Motor Sports House, Riverside Park, Colnbrook, SL3 0HG Page 5 of 6

7 Appendix 1 MSA bank details for BACS payment Please transfer your remittance directly to our bank Please include Track Licence in the payment reference Our Pound Sterling bank details: National Westminster Bank Belgravia Branch 141 Ebury Street London SW1W 9QP Sort Code: Account No: Account Name: Motor Sports Association Swift Code: NWBK GB 2L IBAN Code GB13 NWBK Page 6 of 6

8 2016 MSA Track Licence application (Kart Circuits only) Appendix 2 Kart Circuit Medical Centre Venue: Medical centre present? If yes, please indicate whether the Medical Centre meets the following requirements of (F)6.4: A room large enough to accommodate a single bed (for the observation and treatment of a single casualty) Equipped with first aid equipment (as required under HSE Code of Practice ACOP 1997 for organisations of 21 to 50 people) Eye wash station with 2 x 500ml of sterile saline solution Set of stiff neck extraction collars (including paediatric sizes) Portable resuscitation equipment * Indicate as applicable Please return completed form, along with completed Track Licence application and correct payment to: Motor Sports Association, Motor Sports House, Riverside Park, Colnbrook, SL3 0HG Page 1 of 1

9 2016 MSA Track Licence application (Race Circuits only) Appendix 2 Race Circuit Medical Centre Venue: Please indicate whether the Medical Centre meets the following requirements of (E)9.3 - (E)9.5: Easy and level access for ambulance and stretchers Offers security from press and public Located in accordance with CAA requirements (allowing a helicopter to be used when necessary) Minimum of 3 sufficiently sized rooms, with adequate heating and lighting Resuscitation room capable of accommodating 2 patients minimum at one time Observation ward capable of accommodating 2 recumbent patients at one time (with total security in the event of death) Treatment area for small dressings and other minor procedures Administration area Shower Washing facilities Toilet facilities Please indicate whether the Medical Centre is equipped in accordance with the following requirements of (F)6.3: Resuscitation: Oropharyngeal airways (eight assorted sizes 2, 3 and 4) Pocket mask or similar device (with non-re-breathing valve and O2 inlet) Suction apparatus mains, battery, hand or foot operated (capable of 300mm Hg suction with reservoir not less than 350ml or overflow system with catheters and wide bore suction) Self-inflating manual resuscitator (with facemask and O2 reservoir) O2 supply (min size F1360 litres) and spare (with reducing valves, flowmeters as necessary) O2 tubing and masks Page 1 of 3

10 Laryngoscopes x 2 (with spare batteries and bulbs) Endotracheal tubes cuffed x 6 (sizes 6.0mm to 9.0mm) Nasopharyngeal tubes x 3 (assorted sizes) Entonox with appropriate on demand delivery system (NB storage regulations) IV cannulae (six assorted sizes 1.0 to 2.0mm) IV administration sets x 6 Hartmanns Solution (or equivalent) 1000ml x 6 (under the direction of a Medical Officer) Haemaccel (or equivalent) 500ml x 8 (under the direction of a Medical Officer) Pressure infusor Assorted syringes and needles Monitoring and diagnostic: Sphygmomanometer aneroid/mercury (for latter consider regulations re Hg spillage) Non-invasive Blood Pressure Monitor Pulse oximeter Defibrillator with leads, electrodes pads/gel ECG Thermometer Blood glucose estimation kit Splints and dressings: Large field dressings x 10 Bandages and adhesive tape in assorted sizes Sterile non-adhesive and adhesive wound dressings Burn dressings and supply of sterile transparent bags assorted sizes Semi rigid cervical collars x 4 (assorted sizes) Splints Page 2 of 3

11 Drugs: Cardiac arrest drugs (according to the European and UK Resuscitation Council Guidelines (1992)) A supply of parenteral analgesics Surgical: Chest drainage kit Cricothyrotomy/Cricothyroidatomy kit Minor op sterile pack (with needle holder, scissors, artery forceps, scalpel and blades) Suture materials Skin antiseptic Small autoclave (recommended) Miscellaneous: Scoop stretcher Casualty immobiliser (vacuum mattress) Stretcher for ambulance * Indicate as applicable Please return completed form, along with completed Track Licence application and correct payment to: Motor Sports Association, Motor Sports House, Riverside Park, Colnbrook, SL3 0HG Page 3 of 3