Berkeley 10 km

Entry Form

 

First Name _______________________________________________________________

 

Surname _________________________________________________________________

 

Club ____________________________________________________________________

 

Sex:_______Age on 17 May 2004:_____________

 

Address:__________________________________________________________________

 

____________________________________________________________________

 

____________________________________________________________________

 

Postcode:______________________________

 

Home telephone no.:____________________________

 

BNFL employee? Please give location:______________________

I declare that I am an amateur as defined by BAF rules and that I will abide by the laws and rules of competition. I will be 16 years of age or older on 17 May 2003. I understand that Dursley & District A C and any person or body involved in the organisation of the event will not be held liable for any injury, illness or loss however occasioned resulting from the event. I will not participate unless I am fit to run.

 

 

Signed: ____________________________________ Date: ____________________________

 

Please make cheques payable to DURSLEY & DISTRICT A C. Entry fees £4.00 attached, £5.00 unattached (£1.00 extra on the night).

Return forms to:

Berkeley 10 km,
Chapel House, The Cross
Nympsfield
Stonehouse
Gloucestershire GL10 3TU

before 13 May 2004. Include an SAE if you require acknowledgement or number, otherwise collect your number on the night.

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Page last modified 9 Feb 2004