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Instructions:

  1. Print this form
  2. Complete the details
  3. All entrants must sign the declaration
  4. Mail with payment to: Entries Manager, PO Box 206, Ettalong Beach, NSW 2257 OR
    fax to (61 2) 4342 7648.
    Do NOT fax and mail your entry
  5. Mailed entries must postmarked no later than 15 March and received no later than Wednesday 20 March.
    Faxed entries must be received no later than 6pm 15 March and include credit card payment details.
    Faxed entries without credit card details will not be accepted
  6. Entry fees are non refundable and entries are non transferable
  7. Entries faxed or mailed AFTER the close of entries date WILL NOT be accepted.
    Late entries are accepted on race weekend ONLY

Postal and faxed entries close: 15 March 2002

Preferred First Name:_________________________________ Surname:_______________________

Postal Address:_____________________________________ Suburb/Town:___________________

State/Country:___________________ Postcode:_________

Telephone:________________________ (work) _______________________(home)

Email address:_______________________________________

Sex M/F___ Age on race day_____ Date of birth ______DD_____MM______YYYY

I am entering (circle as appropriate): 5k 10k Marathon 50k Wheelchair Amb.Disabled

Marathon Entrants to complete this section


First Marathon y/n___ Personal best ____hr_____min____s Year______ Est. race time_________

Are you a member of a State Masters (Veterans) Athletic Club y/n ___

If so, name of State club:_________________________________


Marathon Entry Fee

 

Fun Run Entry Fee

 

$55 if postmarked no later than 15 March

$_______

$18 adult/$12 under 20 if postmarked no later than 15 March

$_______

$50 if ACTCCC member

$_______

$40 if family entry (pin forms together)

$_______

$80 for all late entries
(race weekend only)

$_______

NIL if marathon entrant

$_______

Merchandise Order

$25 adult/$20 under 20 if late entrant (race weekend only)

$_______

Short sleeve T shirt
@ $25 Size ____

$_______

Pasta Party

 

Long sleeve training top
@ $45 Size____

$_______

____ guest(s) @ $24

$_______

Polar fleece top
@ $45 Size____

$_______

TOTAL REMITTANCE
(all fees include GST)

$_______


  • Payment by Visa/Bankcard/Mastercard/Cash/Cheque/Money Order (please circle one)
  • Please make cheques payable to ACT Cross Country Club
  • For Visa, Bankcard or Mastercard, please complete the following:

Cardholder's Name:__________________________________________

Cardholder's Signature:_______________________________________

Card No: ___________________________________ Expires: ____/____


 Please note: Entry form must be signed below

  1. I have read the conditions of entry for this event and understand the demanding physical nature of the
    event. I have trained for this event and I am not aware of any medical condition or impairment that may
    be detrimental to my health if I participate in this event. In the event that I become aware of any medical
    condition or impairment, or am otherwise sick or injured prior to the event, I will withdraw from the event.
  2. I acknowledge that participating in this event may involve a real risk of serious injury or even death from
    various causes including: over exertion, dehydration and accidents with other participants, spectators
    or road users.
  3. I acknowledge that it is a condition of participating in this event that I do so at my own risk. I accept all
    risks and release the event organiser, its agents, affiliates, employees, members, sponsors, promoters,
    volunteers and any person or body directly or indirectly associated with the event, from all claims,
    demands and proceedings arising out of or connected with my participation in this event and I indemnify
    them against all liability for all injury, loss or damage arising out of or connected with my participation in
    this event. This release continues forever and binds my heirs, successors, executors and personal
    representatives.

Signed: ________________________________ Date: ____/____/_____

 

To print click here

On line entry through Enter On Line will be available shortly.

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