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LIONS CLUB OF ELERMORE VALE INC present the

28th MARCH 1999

10.00am START

To enter:Print this entry form, complete & sign it, then snail-mail it with a cheque or money order for the entry fee $10 per person (adults and children) payable to 'Elermore Vale Lions Club' to Jim Cowburn, 137 Reservoir Rd., Cardiff, NSW 2285.

DECLARATION: I, the undersigned, in consideration of and as a condition of acceptance of my entry in the Shaft Shuffle organised by the Shaft Tavern Elermore Vale for myself, my heirs, executors and administrators, hereby waive all and any claim, sight 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 waive, release and discharge shall be and operate separately in favour, all persons, corporations and bodies involved or otherwise engaged in promotion or staging the event and the servants, agents, representatives and officers of any of them. 3. I declare that I take part in sport only as an amateur and will abide by the competition rules and will accept the organisers' decision as final.

NAME................................PH:..............(ah)...............(bh)

ADDRESS...................................................P/CODE........

SIGNATURE...............................AGE:...........D.O.B............

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This form was downloaded from the Shaft Shuffle web site, http://www.coolrunning.com.au/races/shuffle/
This page has been on line since 27.12.97, & was last updated on 27.3.99

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