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Instructions:
Print this form, fill it in and mail with payment by Friday 18 June to:
Race Secretary, PO Box 367, Warners Bay, NSW 2282.
Please make cheques payable to The Lake Macquarie International Half Marathon Inc.
All entrants must sign the declaration.

Personal Information

First Name:______________________

Street:__________________________

State:___________

Phone (home):_______________

Surname:________________________

Suburb:_________________________

Post Code:_____________

Phone (business):_______________

Category Information

Sex (Male / Female):_____________

Date of Birth:_____________

Age on 21 June 1999:_____________

Registered Newcastle Hunter Region Athlete (Yes / No):_____________

Lake Macquarie Resident (Yes / No):_____________

Division (please circle): 1  2  3  4  5  6  7

Teams

Complete only if entering a team ...

Team entries must be entered all together and each athlete must complete a separate form.

Team Name:______________________________

Fee

Half Marathon Entry (incl. Result Sheet):	$25  ________

Late Entry (Saturday 12 - 4 pm):		$28  ________

Late Entry (Sunday):				$30  ________

Total Fee:					  $  ________			

1. I, the undersigned, in the consideration of and as a condition of my entry in the Lake Macquarie International Half Marathon, for myself, my heirs, executers and administrators, hereby waive all and any claim, right or cause of action which I or they might otherwise have for or arising out of loss of my life or injury, damage or loss of any description whatsoever, which I may suffer or sustain in the course of or consequent upon my entry or participation in the said event.
2. This waiver, release and discharge shall be operated separately in favour of all persons, corporations and bodies involved or otherwise engaged in promoting or staging the event and the servants, agents, representatives and officers of any of them, and includes but if not limited to the Lake Macquarie International Half Marathon Inc. Medical and Paramedical Practitioners and Personnel, Police Officers, Lake Macquarie City Council and Athletics Australia and shall so operate whether or not the loss, injury or damage is attributed to the act or neglect of anyone or more of them.
3. I, the undersigned have read the Declaration and Rules of this competition.

Signed:____________________________ Date:____________________

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