This Entry form is for the 2010 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 23 April 2010.
• Please make all cheques payable to Wainuiomata Athletic & Harrier Club.
• 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 (2/5/10):	_____	Runner    Walker
Event entered:	12km Run	12km Walk
	5km Run	5km Walk
Club Name:	__________________________________
	Enter 'casual' if not a club member

How did you hear about this event?

 Newspaper     Radio     Cool Running    Word of mouth
 Other (please specify) ______________________________

Payment Details

Entry fee for 12km Run & Walk: $30
Entry fee for 5km Run & Walk: $10
Late Entry Fee (after 23 April add): $5

1. I acknowledge that I compete entirely at my own risk.
2. I agree to abide by the race rules.
3. I authorise any information give on this entry form to be used for promotional and / or result purposes pursuant to the Privacy Act 1993.
4. The organisers shall not be liable for any disruptions caused by any event or occurrence beyond their reasonable control.
5. I understand my entry fee is non-refundable.

Signed:________________________________________

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