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Get Fit in a Friendly Way
Learn to Run 5 km in 9 weeks
Registration Form – March 2015
(Please Print, * = minimal required information)
First name*
______________________________________________
Surname*
______________________________________________
Date of Birth*
___/___/___
Sex*
(Only people aged 18 or over can register)
Male / Female (circle one)
Address*
______________________________________________
Suburb*
______________________________________________
City*
______________________________________________
Email
______________________________________________
Phone/Mobile*
______________________________________________
Registration Fee $ 40.00
Indicate payment method:
Cash payment enclosed
Cheque enclosed; cheque made payable to
Run Walk Hawke’s Bay
Paid by direct credit to Westpac, Napier,
Account no 03 0698 0347988 00. Please use as
references your surname and ‘course’.
Send this form plus payment (if cash/cheque) to
Run Walk Hawke’s Bay, c/o 25 Birdwood Street,
Napier 4112, by Wednesday 4 March 2015
Please check:
Declaration (To be completed by ALL registrants.)
I declare that: I have read the course information and
am aware that during the sessions of the course road
rules apply at all times and there are no road
closures. In the event of an “ACT OF GOD” conditions
causing a cancellation of one or more sessions of the
course, my registration fee is NOT refundable. Neither
the organisers of the course nor Run Walk Hawke’s
Bay shall have responsibility for any liability, financial
or otherwise, which might arise whether or not by
negligence from any direct or indirect loss, injury or
death which might be sustained by me or any other
party directly or indirectly associated with me, from
my intended or actual participation in the course or
any other activities organised by Run Walk Hawke’s
Bay. I agree to abide by the Rules as stated in the
Club’s Constitution and as set from time to time by the
Executive. I authorise my name, voice or picture to be
used without payment to me in any results, broadcast,
telecast and/or promotion pursuant to the Privacy Act
1993.
Have you completed your details?
Have you signed the declaration?
Have you indicated your payment method
and made your payment?
Signature: __________________________________
Date:
__________________