Addo Elephant Trail Runs 2009 ~ Registration Form

COMPLETE FORM IN BLOCK LETTERS, SCAN AND EMAIL TO nadia@extrememarthons.com OR FAX TO 086 609 7755

(SHOULD YOU HAVE ANY QUERIES, KINDLY CONTACT US BY EMAIL, FAX OR TELEPHONE)

Last Name:                                                     First Names:

Male/Female:                                                 Age & Date of Birth:

Nationality:                                                     ID/Passport No:

Postal Address:

Country:

Tel. Nos.(insert country code):  Home:                                       

Work: Mobile:                                                Mobile:

Email:

Next of Kin (in event of emergency):

Telephone No (insert country and code):

T-Shirt size:                                                   Socks size: 

South African Participants 

Medical Aid and No:

My Medical Aid covers me for Extreme Sports of this nature.   Yes     No

International Participants - Travel Insurance Details

Please reserve the following on my behalf:

R950.00 ~ Addo Elephant 100Miler Trail (Limited to 100 Participants)

R550.00 ~ Addo Elephant 50Miler Trail (Limited to 200 Participants)

R350.00 ~ Addo Elephant 25Miler Trail (Limited to 200 Participants)

Registration is based on the event details stated in the itinerary for the Addo Elephant Trail Runs 2009.

(Please tick the following)

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I am in good physical and mental health, and fully realize the risks involved in participating in an extreme event such as the Addo Elephant Trail Runs.

____

In submitting this booking application, I hereby indemnify and hold harmless Augrabies Extreme Marathon cc, its’ employees, volunteer helpers, sponsors and agents from all losses and injuries sustained by me.

____

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/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 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".

Signature of Competitor:

Signature of Parent/legal guardian if under 21: 

Date:                                          Place: