This Entry form is for the 2011 event only!

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

Race Secretary
Wainuiomata Mountain Fun Run & Walk
PO Box 43 056
Wainuiomata 5048

• Entries must be received by 3 September 2011.
• Please make all cheques payable to Wainuiomata Athletic & Harrier Club.
• or pay directly into our bank account no. 06-0569-0145810-00 before 3 September.
• Please complete this entry form in BLOCK letters.
• All entrants must sign the declaration.

Your Details

Surname:	__________________	First Name:	__________________
Postal Address:	__________________________________
	__________________________________
	__________________________________
email Address:	__________________________________
Phone:	__________________	Gender:  M     F
Age on day of race (10/7/11):	_____	Runner    Walker

Payment Details

Entry fee for 12km Run & Walk: $30
Entry fee for 5km Run & Walk: $10
Late Entry Fee (after 3 September) add: $5

1. I acknowledge that I compete at my own risk.
2. I agree to abide by the race rules.
3. The organisers shall not be liable for any disruptions caused by any event or occurrence beyond their reasonable control.
4. I understand my entry fee is non-refundable.

Signed:________________________________________