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KEMBLA JOGGERS Presents:

Entry Fee: Indiv: $7, Family: $15 Late Entry Fee: Indiv: $10, Family: $20
Cheques to be made out to: Kembla Joggers
Print this form, complete & post to: Kembla Joggers PO Box 527 Dapto 2530
Enquiries AH: Jim Hennessey (02) 4229-2490, or Mark Everton (02) 4284-5379

SURNAME: Mr, Ms, Mrs, Miss ------------------------------------------------------ SEX: M or F -------

FIRST NAME:--------------------------------  DATE OF BIRTH: ------------

ADDRESS:-------------------------------------------------------------------- POSTCODE:----------  

PHONE NUMBER:-------------------------------------- PLEASE SEND INFO ON KEMBLA JOGGERS: Y or N ----------  

T-SHIRTS AT $5 EACH: S ---------- M ---------- L ---------- XL ----------

TEAM/SCHOOL/CLUB NAME:---------------------------------------------  RUNNER'S No. (Office Use only) ----------

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INDIVIDUAL ENTRY - Please circle one letter only Female CATEGORY Male A Runners under 12 years B C Runners 12 - 14 years D E Runners 15 - 17 years F G Runners 18 - 29 years H I Runners 30 - 39 years J K Runners 40 - 49 years L M Runners 50 - 59 years N O Runners 60 years plus P S Walkers Open T Q Walkers 40 years plus R U Wheelchair V

TEAM ENTRY - Please circle one only Open Female        Open Male 40 Plus Female        40 Plus Male Family 3 person        Corporate Junior Female under 13        Junior Male under 13 Junior Female under 18        Junior Male under 18 SCHOOL PRIZES * Most Number of Entries * School Challenge Shield * TEAM ENTRIES CLOSE Wednesday, April 12th Please submit all team members' entries in the same envelope NO TEAM ENTRIES ON THE DAY

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DECLARATION: I have read and understood the Conditions of Entry and agree to abide by the rules and conditions which govern the event.

Signed by the Entrant____________________________ Date:____________________

If you are 18 or under, this part must be signed by your parent or guardian. I certify that I am the parent or guardian of the Entrant who is ____ years of age and has my consent to run in this fun run and I agree that my son/daughter and I will be bound by the above Conditions of Entry.

Signed by the Parent or Guardian_________________________ Date:_________________

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This form was downloaded from the fitness 5 web site http://www.coolrunning.com.au/races/fitness5/
Back to the Fitness Five Home Page

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