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Surname:	______________________
First Name:	______________________
Address:	______________________
Suburb:	______________________
Phone:	__________(H)	__________(W)
Email:	______________________
Age as at 26/8/2001:	______	Sex:	______
Burke Hall Students State Year Level	______

Event Entered Please tick one ...  15km Run  7.5km Run  5km Run  7.5km Walk  5km Walk

How did you find out about the DeCastella Fun Run? Please tick one ...  Runners World  Runners World  Runners World  Runners World  Runners World  Runners World  Runners World  Runners World  Runners World

I acknowledge and accept that running/walking can be a hazardous activity and I waive all and any claim or cause of action which I or my heirs executors administrators in or anyone else who may have a claim on my behalf in or in connection with loss of life, injury loss or damage of any description which I may suffer or sustain as a consequence of participating in the event. This waiver release and discharge shall operate in favour of all persons, corporations and bodies involved or otherwise involved or otherwise engaged in the event and the servants and agents representatives and officers of any of them including but not limited to City of Boroondara Burke Hall Victoria Police St John Ambulance and shall opearte whether or not the loss injury or damage is attributable to the act neglect or default of any one or more of them

SIGNATURE: __________________________