The Mauku 10km & 5km Run and Walk

The Mauku 10km & 5km run & walk
March 21^st 2010

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~Entry Form~

Instructions: Print this form, fill in and mail with payment to: Mauku Fun Run, 389 Union Road, RD 3, Pukekohe 2678. Closing date is 15^th March 2010; Late entries taken on the day.

Surname	__________________________________________
First name	__________________________________________
Address	__________________________________________
	__________________________________________
	__________________________________________
	__________________________________________
Phone (home)	___________________	(bus)	_________________
e-mail	__________________________________________
Event (Please tick)	10km run		5km run
	10km walk		5km walk

Entry fee

10km	$20.00
5km	$15.00
Late entry fee (after 15 March) add	$ 5.00
Cheque enclosed	_______

Make cheques payable to Mauku Primary School.
No Credit Cards or Eftpos available.

Declaration
Neither the organisers, the sponsors nor any party associated with the event shall have any responsibility for any liability, financially or otherwise, which might arise whether or not by negligence, from any direct or indirect loss, injury or death which might be sustained by me or any party directly or indirectly associated with me, from my intended or actual participation in the event and its related activities. In the event of any 'act of god' causing a cancellation of the event, or personal circumstances preventing me from participation my total fee is non-refundable.

Signed__________________________________ Date____________________