COAST ROAD 16km CLASSIC 2006

ENTRY FORM

NAME:________________________________________________

ADDRESS:____________________________________________

______________________________________________________

PHONE #___________ EMAIL:__________________________

CATEGORY: (circle one)

ENTRY FEES: Unregistered: $17.00
Registered runner discounted fee $12.00 ANZ Reg #________
Late fee $5.00 Club_____________
TOTAL ENCLOSED: ______

Entry fees are payable to "Leith Harriers" and entries may be posted to race secretary Margaret Knox, 83 Glenross Street, Dunedin or email raybmarg@xtra.co.nz.

Entries may also be dropped off at "The Frontrunner", 261 George St, Dunedin. Late fees will apply to
entries received after Monday 11 September 2006

Declaration to be completed by all competitors
Neither the organizers, the sponsors or any party associated with the event shall have any responsibility for any liability, financial or otherwise, which might arise whether or not by negligence, from any indirect loss, injury or death which might be sustained by me or any other party directly or indirectly associated with me, from my intended or actual participation in the event and its related activities.
I authorize my name, voice or photo, or any information given on this entry from to be used without payment in any broadcast, telecast, advertising, promotion in any other way relating to this event pursuant to the Privacy Act 1993.
I compete at my own risk, and I understand my entry fee is non-refundable after closing date.
I will be 16 years of age or older on the day of the race.

Signed:____________________________________