Addo Elephant Trail Run ~ Registration Form 2011

Complete form in block letters, email to nadia@extrememarathons.com or fax to +27 (0)86 609 7755
General Information
First Name: Surname:
Male/Female: Age & Date of Birth:
ID/Passport Number: Nationality:
Postal Address: 
Telephone Nos.: Mobile:
Home: Work:
Email (block letters):
T-Shirt size: Allergies:
South African Participants 
Medical Aid and No:
Main Member: Medical Aid Tel. No.:
International Participants
Travel Insurance Details:
In event of emergency:
Name: Contact No.:
Email (block letters):
Please reserve the following on my behalf.

Event

Price in ZAR

Tick Req. Event

85 km

R650.00

  

50 km

R400.00

  
Please tick the following
  I acknowledge that I am aware that the Addo Elephant Trail Run is an extreme and accordingly a potentially dangerous activity. Although stringent safety measures will be in place, the risk of personal accident or injury cannot be completely excluded.  I confirm that I am physically and mentally well and fit and am able to participate in exercise of this nature without undue risk to my health.
  I hereby undertake and agree to indemnify and hold harmless all land owners, Augrabies Extreme Marathon cc, its’ employees, volunteer helpers, sponsors and agents against any liability and against any/all proceedings, claims, damages, interest, costs, and/or expenses which may result from any accident or injury to myself or my belongings.
  I grant my permission to use my name, race information and photographs, video tapes, broadcasts and telecasts in which I may appear, free of charge.
  If my Medical Aid/Travel Insurance does not cover me for this type of event, I fully accept that ALL evacuation/hospitalization/medical costs will be for my own expense as laid out in the Conditions of Contract.
  I grant my permission for the Event Medical Team to administer any medication deemed necessary by them.
  I confirm having read and fully understood the Rules and accepted the “Terms and Conditions” of this contract as more fully set out in "Conditions of Contract".
 

Date:  ______________________________      Place:  _____________________________

Signature of Competitor :  ______________________________________

Signature of Parent/legal guardian if under 21:  _____________________________