| Member name: | Membership # | Date: |
| Rocket Name: | Location: |
| Has flown successfully before ? | Total Lift Off Weight: | Thrust to Weight Ratio: |
| Ready to assemble kit | Scratch Built | Rebuilt |
| Single/First Stage | Motor(s): |
| Streamer | Parachute | Other |
| Ejected By Motor | Ejected By Altimeter/Timer | Dual Deployment |
| Second Stage | Motor(s) |
| Streamer | Parachute | Other |
| Ejected By Motor | Ejected By Altimeter/Timer | Dual Deployment |
| Third Stage | Motor/s |
| Streamer | Parachute | Other |
| Ejected By Motor | Ejected By Altimeter/Timer | Dual Deployment |
| Model Rocket (a,b,c,d power <453g ) |
Large Model Rocket
(Up to H power, <1.5 kg) |
High Power | Experi- mental |
| Estimated Altitude | Actual Altitude (if available) |
| RANGE SAFETY OFFICER USE ONLY |
| CP/CG | THRUST/WEIGHT | ATC REQUIRED | ATC NOTIFIED |
| COMMENTS |
| PLEASE NOTE THAT BY SIGNING BELOW YOU AGREE THAT: This rocket complies with the NZRA safety code, is well constructed following the manufacturers instructions (kit) and sound materials and methods have been applied for scratch built/rebuilt. |
| Member/Parent/Guardian |
| Range Safety Officer |