IRIS HOUSE – RUN, WALK and ROLL
ENTRY FORM
WHEN: 27 th October 2018
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 24th of October – Trophies , prizes for best dressed etc
Theme: Superhero’s
Time: 10am
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 24th 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) |