EmailMe Form - Kosciuszko Run/Half Marathon 2013 Entry Form

Pick One *

Kosciusko Run (11 km)

Kosciusko Half Marathon (22 km)

Which one will you participate in.

Name *

First Last

Address *

Street Address City State / Province / Region Postal / Zip Code Country / Region

Home Phone

Format example: (03) 1234-5678
Please include your area code.

Mobile Phone *

Format example: 0412-345-678

Work Phone

Format example: (03) 1234-5678

Email *

Confirm

Sex *

Female

Male

Date of Birth *

DD / MM / YYYY

Remittance enclosed: Cheques should be made out to Strzelecki Heritage Inc.

Entry Fee *

I agree to pay the $25 fee using the methods specified below by 1st February 2013

Donation to the National Heart Foundation ($)

Declaration

1. I, the undersigned, in consideration of and as a condition of entry in the 2013 Kosciuszko Run/Half Marathon (or its substitute on the day in the event of cancellation) for myself, my heirs, executors and administrators, hereby waive all and any claim, right or cause of action which might arise out of loss of my life or injury or damage consequent upon my entry or participation in the said event. This waiver, release and discharge shall be and operate separately in favour of all persons, corporations and bodies involved or otherwise engaged in promoting or staging this event.

2. I have trained for this event, have no medical impairment which may be detrimental to my health, and I will withdraw from the event if I suffer a viral complaint during the last seven days before the race, or I feel unwell on the day.

Signature *

I agree to the above declaration and will follow it accordingly.

Date *

DD / MM / YYYY

Send entry fee to Kosciuszko Run, 52 Valley Fair Dr., Narre Warren, Victoria 3805

OR

You can pay entry fee to (bank):
Strzelecki Heritage Inc.
BSB - 633000
Acc. No. - 138611553