Mt Buller Entry Form
From AURA
Back to Mansfield to Mt Buller
7am, Sunday 28th January 2007
It is important to write clearly in BLOCK LETTERS and leave space between words/numbers where applicable
Surname .........................................
Firstname .........................................
Sex (M or F) ...........
Date of Birth(DD/MM/YY) ..............................
Address (number/street) ....................................................................................................
Suburb, State, Pcode ..............................................................................................
Telephone (indicate work, home, mobile) .........................................
PERSON TO BE NOTIFIED IN CASE OF EMERGENCY
Surname .........................................
Firstname .........................................
Relationship .........................................
Telephone (indicate work, home, mobile) .........................................
WAIVER
I, the undersigned, in consideration of and as a conditon of acceptence of my entry in the Mansfield to Mt Buller 50km Road Race, for myself, my heirs, my executors and administrators, hereby waive all and any claim, right or causes of action which I might otherwise have for, or arising out of, loss of life or injury, damage or loss of any description whatsoever which may suffer or sustain in the course of, or consequent upon my entry or participation in the event. I will abide by the event rules and conditions of entry or participation. I attest and verify that I am physically fit and sufficiently trained for the completion of this event. This waiver, release and discharge shall be and operate 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.
Signed ........................................
Date ........................................
DEDICATION DETERMINATION DISCIPLINE
Plus a new note of caution from the race organiser : Remember the 6 Ps !
Prior Preparation Prevents Piss Poor Performance !
