Berkeley 10 km

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: ____________________________