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Langebaan Lagoon Crossing 2014 - Entry Form
Please complete one for each participant
Entry fee of 70 pp payable at registration on the day of event
Name
*
First
Last
Email Address
*
Date of Birth
*
MM
/
DD
/
YYYY
Cell Number:
*
Hometown:
*
Participation
*
Swimming
Rowing
Sub / Surfboard
Land Support
Other
Emergency Particulars:
Name
*
First
Last
Relationship
*
Cell Number
*
Do you suffer from any allergies or medical conditions?
(If YES, please elaborate...)
*
Other Questions:
Please indicate whether you have done the Lagoon Crossing before:
*
2010
2011
2012
2013
Nope, this is my first time
Do you have a Wild Card?
*
Yes
No
Does your household sort domestic waste for recycling?
Yes
No
(Be honest)
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