Name of Run
SURNAME .. FIRST NAME ..
NATIONALITY .. AGE
DATE OF BIRTH SEX
CITY .. STATE
POSTCODE COUNTRY .
TELEPHONE . FAX NUMBER .
EMAIL ADDRESS .
NAME OF CREW MEMBER ..
RUNNER OR WALKER .
REGO NUMBEROF CREW VEHICLE/OR CONTRACT NUMBER FROM VEHICLE HIRE COMPANY .
YOUR QUALIFICATIONS TO ENTER THIS RUN
I certify I have read, understood and agree to abide by the General Rules of the .. I further understand that my crew will also be required to agree to the General Rules and sign the Accident Waiver and Release of Liaibility/Release of Name and Likeness form.
Signature . Date
Print Name ..
Complete this form and mail it together with signed entrant Contract and Accident Waiver and Release of Name and Likeness forms and a check or money order for $100 AUD by December 31st 2002 and the rest of the entry fee($400AUD) by January 30th 2003.
Please make the check/money order payable to:
We will contact you as soon as possible as to wether your entry has been accepted or not.