1000KM & 500km RUN ENTRY FORM
SATURDAY, 27 OCTOBER 2012
NAME & SURNAME: …………………………………………………………………………………………………………
ID NUMBER: ………………………………………………………………………………………………............
BLOOD TYPE: ………………………………………………………………………………………………...,……..
MEDICAL FUND: ………………………………..…….…………… NR : ……………..……..………………………
POSTAL ADRESS: ………………….……………………………………………..………………………………………
………………………………………………………….……………………………………………..
ALLERGICS: …………………………………………………………………………………………………………………….
CELLPHONE NUMBER: ………………………….……………… FAX NUMBER: ………………………………...........
E-MAIL ADRESS: ………………….………………………………………………..…………..………..………………..
CONTACT NR IN CASE OF EMERGENCY: ……………..………………………………………………………..………..
CLUB NAME: ……………………………………………………………………….………………………..………..
MOTORBIKE: ………………………………..……… BIKE REG. NR: ………………………..……………..
PASSENGER NAME: …………………………………………………….……………………………………………………...
( PASSENGER TO FILL IN SEPARATE FORM )
PLEASE INDICATE FOR WHICH CATEGORY:
1000KM
|
500KM
|
T-SHIRT SIZE : ……………………………………………………………………………………………………
I HEREBY AGREE THAT I AM ATTENDING THE RUN ENTIRELY AT OWN RISK AND INDEMNIFY THE ORGANISERS AGAINST ANY DAMAGES SUSTAINED BY MY PERSON OR BELONGINGS. I AGREE TO ABIDE BY THE RULES AND INSTRUCTIONS OF THE ORGANISERS. I ACKNOWLEDGE THAT I HAVE READ THIS DOCUMENT AND FULLY UNDERSTAND THE CONTENTS, INSTRUCTIONS AND INFORMATION IN THE ENTRY FORM
…………………………………… ………………........................
RIDER SIGNATURE PASSENGER SIGNATURE
PLEASE EMAIL COMPLETED FORM + PP TO: femsuskonstruksie@gmail.com / FAX: 086 532 7285 / 7278
BANK DETAILS:
HARTIES BIKING COMMUNITY, ABSA ACC: 9253895243 TAK: 632005
ENTRY FEE: R300 P/P
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