Instructions: Print this form, fill it in and mail with payment to:

N.B. All entrants must sign the waiver.

Surname: ____________________	Christian Names:  ____________________	

Address: ___________________________

	 ___________________________

	 ___________________________


Male / Female: _________DOB:___/___/___Age on race day: _______

Personal Profile

Other walks you have done? Married? Family? Anything else?

____________________________________________________________

____________________________________________________________

____________________________________________________________

Please use your walk to raise funds for your favourite charity.

Which charity will you be walking for? _________________________

Name of your crew person/s: 	       _________________________

     				       _________________________



Entry Fee:			$35		__________
(includes afternoon tea
for walkers and crew at finish)

Pre Race Breakfast:		$8 per head	__________

Evening Meal			$7 per head	__________
at Kumbia Hotel

Bunkhouse accommodation		$16 per head	__________
at Bunyas:

TOTAL PAYABLE:					__________

I have read and agree to abide by the conditions as stated. I am medically fit and have adequately prepared for this event. I, my legal heirs and support crew will not hold the race director or organisers responsible for any injury, illness or accident sustained, or for loss of property or death resulting directly or indirectly by my participation in this event.

Signed: ______________________ 	Date: ___/___/___