021 910 1578 info@iris-house.org

Entry Form RunWalknRoll 2017

 

IRIS HOUSE – RUN, WALK and ROLL

ENTRY FORM

 

WHEN:  29 th October 2017

VENUE: Iris House Children’s Hospice

Grounds of Stikland Admin (entrance off Old Paarl Road)

COST:     R 40 Adults, Under 12-Free -medals for all participants registered prior to 26th of October – Trophies , prizes for best dressed etc

Theme:    Superhero’s

 

Join us after the event on our Hospice grounds for various market stalls, spot prices and a chance to ride on a Harley.

 

Entry fee to be paid via EFT or PAYFAST

 

 

Entries:  Full Names

 

Adults:

 

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Under 12’s:

 

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Person completing this entry

 

 

 

Name …………………………………………….

 

Email Address ……………………………………

 

Cell Number ……………………………………..

 

Total Number Adults ……………………….

 

Total Number Children under 12  ………………….

 

 

 

 

 

Which event our you entering (please mark with an X)

 

Adult               Under 12’s

 

Run

 

Walk

 

Roll

 

 

Bank Details

Account number:    Iris House Children’s Hospice

Name of Bank:       FNB N1-City

Account Number:  62314506108

Branch Code:         250655

Reference RWR and you name

Your completed registration form and fee returned to us by the 26th of October .

Please email to info@iris-house.org or via fax 0866413233

 

 

 

 

 

 

 

 

Medical Indemnity:

I know that participating in the Run, Walk and Roll event is a potential hazardous activity.  I present that I am medically able and properly trained to participate in this event.  I assume all risk associated with this event including, but not limited to heat exhaustion, falls and or contact with other participants, effects of weather, etc all such risk being known and recognised by me.  I give permission for the administration of medical aid in case of an emergency.  I also hereby give permission to the media to use my name, image or other account of my participation in this event, any publication, newspaper, broadcast, telecast, or other media without limitation and obligation to anyone.

 

Release of liability:

I hereby waive, release and forever discharge the Iris House Children’s Hospice and it’s respective directors, staff, volunteers, any and all sponsors, suppliers and any other personnels assisting or connected with this event, any rights, claims and demands therefore which I may have or which I may hereafter accrue to me arising out of injury to my person and or my property incurred in connecting with participating in the Iris House Run, Walk and Roll event held on the 29th of October 2017

 

 

Name& Surname  _________________________________________________Age: ___________

 

Gender: ________________   Cellphone  Number _____________________________________

 

Email _______________________________________

 

 

Signature: ____________________________________ (parent or guardian signature if under 18)