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
© Copyright 2024