2019 Defensive Driving Course Form

Part 1 – Personal Details.  Please complete all fields

Part 2 - Emergency Contact.  Please complete all fields

Part 3 – Vehicle Details.  Please complete all fields.  Vehicles must be road registered

Part 4 - Fifth Gear Motoring terms & conditions

  1. Fifth Gear Motoring reserves the rights at any stage and without compensation or refund of any fee paid by me, to forthwith in its absolute remove me from any course.
  2. I understand that participating in Fifth Gear Motoring programs carries a degree of risk to the person and property. Knowing the risk I still intend to participate and hereby expressively agree to assume the risk of injury and damage while participating in Fifth Gear Motoring courses.
  3. I shall at all times whilst undertaking said driving course to be subject to the directions of the servants and agents of Fifth Gear Motoring in all respects.
  4. I acknowledge and declare that the motor vehicle supplied by myself to be used on the said driving course is in safe and roadworthy condition having regard to the course and speed which will be produced and that Fifth Gear Motoring shall be under any obligation to scrutineer or examine the same at any time, notwithstanding Fifth Gear Motoring shall be entitled to do so at their discretion. 
  5. I declare and confirm that I am physically fit and have no conditions or injuries that could be affected by my participation in the said course. I acknowledge that it is a fundamental condition of my participation in the said course that I have notified Fifth Gear Motoring and or its servants of any existing medical condition which may affect my participation in the said course and which may exacerbate or deteriorate as a result of an injury sustained during the said course.
  6. I am not taking any medication/drug/ alcohol that would impair my faculties or otherwise affect my ability to safely control a motor vehicle. All Fifth Gear Motoring courses are drug and alcohol-free environments by both participants and spectators.
  7. I hereby consent to receive medical treatment that may be deemed necessary by Fifth Gear Motoring and or its servants in the case of injury, accident or illness in the course of undertaking a Fifth Gear Motoring course and agree to indemnify Fifth Gear Motoring in respect of such medical treatment.
  8. I have a current drivers licence, the details of which are correctly recorded below.
  9. I do hereby for each of our heirs, executors and administrators release Fifth Gear Motoring and all their officials, employees, representatives or agents collectively and individually from all actions, suits, claims and demands for any loss, damage, injury or cost incurred or sustained or made by me arising directly or indirectly out of my participation in any capacity in a Fifth Gear Motoring course and furthermore I agree to indemnify Fifth Gear Motoring and their servants, representatives and agents from and against all actions, suits, claims and demands or other liability in respect of death or injury to any person including myself and the loss or damage to the property of any person, company or organization including myself however arising out of, or in conjunction with my participation in a Fifth Gear Motoring course and notwithstanding that the same may have been contributed to or caused by the negligence or fault of Fifth Gear Motoring or their officials, servants, representatives or agents.
  10. I give consent for any photos taken during this course to be used for Fifth Gear Motoring promotional use.