Bib No:
LATE ENTRY FORM
(Office use only)
Event details
Event:
Individual
$350
(incl.GST)
Team
$410
(incl.GST)
Category: * Please find categories
over page. Categories are determined
by your age as of 31/12/14.
Your details
First name
Date of Birth
Surname
Male
Address
Email address
Suburb
Phone
State
Postcode
/
/
Female
Age (at 31/12/14)
TA Number
Emergency contact details
Contact name
Contact
number
NOTE: This section must be completed: Emergency contact person must be contactable on this number and cannot be another
competitor.
Medical
Conditions
Credit Card payment details
Visa
Mastercard
Card expiry date
Total amount $
Card number
(inc. GST)
Signature
Card holders
name
Declaration
Your
signature
NOTE: MUST BE SIGNED - Please read the Terms & Conditions
over page and sign as a condition of entry.
Please return to [email protected] or fax to 03 9646 1559 by 5pm AEST Wednesday 15 October 2014.
Any entries after Wednesday 15 October will need to be handed to the help desk at Check-In on Friday 17 and Saturday 18 October only.
www.ironmanportmacquarie.com
Phone: 1300 835 411
Email: [email protected]
Individual Categories
Code
A
B
C
D
E
F
G
H
I
J
K
L
M
N
O
P
Q
R
S
T
U
V
W
X
Y
Z
YY
ZZ
Category
Pro
Pro
18-24
18-24
25-29
25-29
30-34
30-34
35-39
35-39
40-44
40-44
45-49
45-49
50-54
50-54
55-59
55-59
60-64
60-64
65-69
65-69
70-74
70-74
75-79
75-79
80
80
Gender
Male
Female
Male
Female
Male
Female
Male
Female
Male
Female
Male
Female
Male
Female
Male
Female
Male
Female
Male
Female
Male
Female
Male
Female
Male
Female
Male
Female
Min. Age
18
18
18
18
25
25
30
30
35
35
40
40
45
45
50
50
55
55
60
60
65
65
70
70
75
75
80
80
Max. Age
24
24
29
29
34
34
39
39
44
44
49
49
54
54
59
59
64
64
69
69
74
74
79
79
-
Category
Male Team
Female Team
Mixed Team
Gender
Male
Female
Mixed
Min. Age
18
18
18
Max. Age
-
Team Categories
Code
MX
FX
XT
www.ironmanportmacquarie.com
Phone: 1300 835 411
[email protected]
USM EVENTS PTY LTD
2014 IRONMAN 70.3 Port Macquarie
WARNING
This is a legal document that affects your rights. If you are uncertain about any terms in this document, you should obtain independent legal advice before
signing.
These terms and conditions apply to all events conducted by USM Events Pty Ltd (USM). Please note that the ironman.com website may contain other terms
and conditions that apply to particular USM events.
USM may require you to sign this agreement on the date of the event even though you have entered online.
By participating in the Event you will be assumed to have read and agreed to the terms and conditions set out on the ironman.com website and within the USM
online registration system, whether you have signed this agreement or not.
If another person has entered you in the Event, that person is assumed to be your agent and that person has accepted on your behalf all the terms and
conditions set out on the ironman.com website and within the USM online registration system.
These terms and conditions are supplementary to the terms and conditions set out on the USM online registration system conducted by Active.com.
If the Event is a triathlon I agree to become a current member of Triathlon Australia as at the day of the Event and will have proof of current membership
available at the event. If I do not have proof of membership available at the Event or I am not a member of Triathlon Australia, I will be required to purchase a
Triathlon Australia one day membership of at the Event.
I understand and agree:
1.
I will review all materials received, accurately complete and agree to the registration information, documents and process, and obey all rules and
policies. These rules and policies include the Athlete Information Guide which is available to download from www.ironman.com the Australian Sports AntiDoping Authority, the Triathlon Australia Race Competition Rules, as may be amended, and all traffic laws;
2.
My final acceptance and participation in the Event is contingent upon USM’s receipt and review of all required information and forms, including this
Form;
3.
I am fully capable of participating without causing harm to myself or others. I further agree that participating in these activities may require extreme
fitness and endurance and that I have the appropriate conditioning and fitness;
4.
USM contracts with individuals or organisations that are independent contractors (not its employees or agents) to provide some of the services and
to conduct some of the activities participants will engage in. I acknowledge that USM does not supervise or control these independent contractors. In addition,
it is accepted that activities take place on premises or at facilities not owned or controlled by USM;
5.
The information provided in this Form is not exhaustive, other unknown or unanticipated activities, inherent or other risks and outcomes may
exist, and USM cannot assure my safety or eliminate all risks. USM representatives are available should I have further questions about the activities or the
associated risks;
6.
I will respect the rights, dignity and worth of every individual at the event including participants, volunteers and spectators. I will at all times act
professionally and responsibly and maintain high standards in respect to my language and actions and will not discriminate against any person on any
grounds but in particular based on sex, sexual orientation, ethnicity, religion, ability or performance;
7.
I am voluntarily participating with knowledge of the risks.
8.
Any dispute or claim/s I may have arising out of, relating to or in connection with this Form, my enrollment or participation in the activities, or any
other aspect of my relationship with USM shall be governed by the law of Victoria, Australia.
9.
If I am signing as the participant’s legal guardian, I have the legal authority to act for the participant and on their behalf.
10.
In regard to my relationship with USM, I agree that the contents of this Form will take precedence over any other forms or contracts I may sign (for
parties other than USM) in connection with these activities.
11.
I authorise USM staff, representatives, contractors or other medical personnel to obtain or provide medical care for me, to transport me to a medical
facility, and to provide treatment (including but not limited to evacuation, hospitalisation, blood transfusions, surgery and medications) they consider necessary
for my health. I agree to pay all costs associated with that care and transportation. I agree, to the release (to or by USM, insurance carriers, other health care
providers and their staff, representatives or contractors) of any medical information or records necessary for treatment, referral, billing or other purposes.
12.
USM reserves the right, in its sole discretion, to dismiss any participant from the activities, to deny or revoke entry of any applicant at any time, to
issue special entries and/or to disqualify participant from the Event. If I am dismissed or depart for any reason, I agree I am responsible for all costs of early
departure whether for medical reasons, dismissal, personal emergencies or otherwise. If my entry application is denied or revoked, I agree that USM is not
responsible for costs incurred or damages suffered by me or my family in excess of the amount of the entry fee. In the event that USM denies or disqualifies
the participant from the Event (either before or during the Event), USM will not refund any entry fees where the participant has misrepresented their eligibility
to participate in the Event at the time of entry or has breached any of the conditions of this Form. If I wish to withdraw from any USM event, I must follow the
specific cancellation instructions as per the event website and the event specific cancellation policy set out on the ironman.com website will apply.
13.
USM, in its sole discretion, may delay, modify, or cancel the Event for any reason, including if it believes the conditions on the race day are unsafe. In
the event the Event is delayed, modified, or cancelled, including but not limited to acts of God or the elements (including without limitation, wind, rough water,
rain, hail, hurricane, tornado, earthquake), acts of terrorism, fire, threatened or actual strike, labor difficulty, work stoppage, insurrection, war, public disaster,
flood, unavoidable casualty, race course conditions, or any other cause beyond the control of USM, there shall be no refund of USM’s entry fee or any other costs
incurred in connection with the Event.
14.
Compulsory insurance cover effected for participants in this Event or future USM events may not cover me for all personal injury, loss or damage
sustained by me.
15.
The Active.com processing fee is non-refundable.
16.
I will immediately advise USM or an Event Official (or another suitable Event official) if I believe or become aware that the race course, facilities,
equipment or areas to be used in the Event are unsafe.
17.
My Event registration is not transferable to other people. Any attempt to transfer my entry or allow another person to participate under my name
may result in cancellation without refund, insurance being deemed as void and disqualification from participating in future USM events.
18.
I grant to USM, its affiliates, designees and assignees the right and permission to photograph, film, record and/or otherwise capture in any media
the name, image, voice, written statement, photograph and/or visual likeness of me and/or my family members (collectively “images”), with right to sublicense,
during the activities or otherwise, without compensation, for use for any purpose in any media throughout the world in perpetuity, including but not limited to
use in broadcasts, photographs, publications, podcasts, webcasts, motion pictures, brochures, CDs, DVDs, internet websites, social media platforms, television,
and/or in any related commercial, informational, educational, advertising, or promotional materials. I understand that all ownership and copyright rights in
the images shall be owned by USM and I waive any inspection or approval rights. I understand and agree that my name, bib number and race results will be
available to the public during and after the Event.
19.
I consent to the Event organisers providing my personal details to FinisherPix which may contact me via email to alert me when photos from the
Event are available on its website, www.finisherpix.com.au.
20.
I consent to my name and contact details being included on the Ironman event database and that unless I specify to the contrary, I will be subscribed
to various USM related publications which include a monthly newsletter and other promotional materials about upcoming events. I acknowledge that I am able
to opt-out of these services at any time.
21.
I agree that if I choose not to be included on the USM event database I will still receive newsletters that relate to the event in which I have registered.
I also agree that it is my responsibility to obtain information and event up dates from the event website, www.ironman.com (if applicable).
22.
I may receive a race timing chip and band at timed events run by USM, which will remain the property of USM. A recorded time is not guaranteed. The
timing chip and band must be returned on the date of the Event at the designated area post finish line. Should I not return my timing band to USM, I agree to
pay $150 to USM within 14 days of the event.
23.
USM may assign this Form to other entity/s or individual/s (“assignees”) at any time, and any such assignment will grant assignees the full rights
and protections accorded in this Form.
24.
This Form is effective in regard to participant’s enrollment or participation in the activities from the date signed through the completion of all
activities, and this Form shall remain in full force and effect following completion of all activities.
25.
I agree to provide the name and contact phone number of a person, who is not a participant in this event, who can be contacted in the event of an
emergency, which person will be available during and after the event.
26.
I am fully responsible for the security of my personal possessions at the Event and USM will not be liable for the replacement of any personal
possessions.
27.
USM is providing a recreational service within the meaning of the Australian Consumer Law and that USM excludes any liability for the death,
physical or mental injury (including the aggravation, acceleration or recurrence of such an injury), the contraction, aggravation or acceleration of a disease,
the coming into existence the aggravation, acceleration or recurrence of any other condition, circumstance, occurrence, activity, form of behaviour, course of
conduct or state of affairs in relation to a participant that is or may be harmful or disadvantageous to the participant or the community or may result in harm
or disadvantage to the participant or the community.
New South Wales
By signing this form, you agree that the liability of USM Events Pty Ltd in relation to recreational services (as that terms is defined in the Competition and
Consumer Act 2010 (Cth) and the Australian Consumer Law) or dangerous recreational activity (as that term is defined in the Civil Liability Act 2002 (NSW), Civil
Liability Act 2003 (Qld) and the Civil Liability Act 2002 (WA)) for any:
a)
Death; or
b)
A physical or mental injury of an individual (including the aggravation, acceleration or occurrence of such an injury of the individual); or
c)
The contraction, aggravation or acceleration of a disease of an individual; or
d)
The coming into existence, the aggravation, acceleration or recurrence of any other condition, circumstance, occurrence, activity, form of behavior,
course of conduct or state of affairs in relation to an individual:
a.
That is or may be harmful or disadvantageous to the individual or community; or
b.
That may result in harm or disadvantage to the individual or community other than that which was caused by reckless conduct.
BIB NUMBER
NAME
EMERGENCY CONTACT
EMERGENCY NUMBER
MEDICAL CONDITIONS
SIGNATURE