ENTRY FORM
RECEIPT NUMBER
Race date: 21 March 2015
OLD MUTUAL OM DIE DAM RACE NUMBER
This section to be completed by both 50 km and 21.1 km athletes
Distance entering for:
50 km
21.1 km
Entries for the 10km & 5km
on the morning of the race only
Surname:
Initials:
M F
Telephone (W): (
V40-49
M50-59
)
Walker
D D M M Y Y Y Y
Date Of Birth:
Category: S18-39
Runner
First Name:
ID Number:
Gender:
Participate as a:
GM60+
Number of ODD races completed:
GGM70+
Telephone (H): (
Cell:
Club In Full:
E-mail
Province
)
Postal Address
Code:
The first 4000 50km & 2000 21km pre-entries receive a free
t-shirt. Indicate your T-shirt size with a tick in the allocated block:
S
M
L
XL
From time to time our sponsor, Old Mutual, may use the information in this entry form to
communicate its products and services that may be of value or interest to you. If you are
prepared to have this information used for this purpose, please place a cross in the box provided.
Would you like to receive future
race information?
Yes
No
Do you want a free Modern Athlete
digi-mag subscription?
Run for more than Yourself
XXL
XXXL
Yes
No
Yes
No
Voluntary donation, please tick:
To donate please visit: www.morethanyourself.co.za
Meerhof School for Physical and Learning Disabilities
House Lesedi home for abandoned babies or babies saved from abortion
SAFV Hartbeespoort service centre for the aged
ENTRY FEES
Payment (please complete)
50km
21.1km
All ages
R250
R100
60-69
R150
R60
70+
R100
R50
Entry Fee
Temp License (R40)
R________________
R________________
ChampionChip Purchase (R120) R________________
Courier (Gauteng) (R65) R________________
Courier (Outside Gauteng) (R105) R________________
All pre-entries close on Sunday 1 March 2015.
NO 50km & 21.1km will be sold on RACE DAY.
Donation TOTAL PAID
R________________
R__________________________
Release and waiver: In consideration of the acceptance of my entry, I for myself, my executors, heirs, administrators and assigns, do hereby release and discharge the Old Mutual OM DIE DAM, any and all sponsors, any and all
volunteer groups, all medical personnel, and and all local authorities from all claims for injuries, damage or property loss I may suffer caused by the negligence of any of them and arising out of my participation in this event, including
pre- and post race activities. I am physically fit and sufficiently trained to participate in this ultra eventand assume all risks for such participation. I accept all rules, conditions and regulations which include the terms of payment of the
entry fee and will comply with them. I undertake not to exhibit o wear any advertising material or logos contrary to the rules of ASA or IAAF.
Signature: ________________________________________________________
Date: ___________________________________
DO GREAT THINGS
*The 50km and 21km events are timed by ChampionChip. No chip. No result. No prize.
PLEASE APPROVE THE ATTACHED PROOF BY PRINTING THIS PAGE AND SIGNING AND DATING AS APPROVED - PLEASE FAX 086 588
4948 OR SCAN/EMAIL BACK TO [email protected]. IN2SPORTS WILL NOT BE HELD RESPONSIBLE FOR ANY ERRORS OR CHANGES
AFTER THE ATTACHED PROOF HAS BEEN APPROVED. COSTS INCURRED DUE TO CHANGES AFTER APPROVAL WILL BE CHARGED TO THE
CLIENT.
__________________________________________________________________________________________
SignaturePrint NameDate