EVENT GENDER I.D. NO AGE ON RACE DAY SURNAME FIRST NAME ADDRESS TOWN / CITY TEL. NO NATIONALITY EMAIL CLUB PROVINCE FULL HALF FULL HALF NUMBER OF COMPLETED WINELANDS MARATHONS PERM NO AND HALF MARATHONS EMERGENCY CONTACT DETAILS NAME RELATION CONTACT NO MEDICAL AID MEDICAL AID NO T-SHIRT NO. COLLECTION FAX ENTRIES PAYMENT MARATHON (CLUB MEMBERS) R 140.00 DEPOSIT IN FAVOR OF: DISPOSABLE TIMING CHIP R 22.00 WINELANDS MARATHON TOTAL R 162.00 ACCOUNT NAME: BALEKA SPORT MARKETING AND DEVELOPMENT MARATHON (NON-CLUB MEMBERS) R 205.00 ACCOUNT NUMBER: 1039754767 DISPOSABLE TIMING CHIP R 22.00 BANK: NEDBANK TOTAL R 227.00 BRANCH CODE: 10470900 HALF MARATHON (CLUB MEMBERS) R 90.00 DISPOSABLE TIMING CHIP R 22.00 USE RUNNER’S NAME AS REFERENCE TOTAL R 112.00 FOR FURTHER ENQUIRIES TEL: 086 005 1021 HALF MARATHON (NON-CLUB MEMBERS) R 145.00 OR EMAIL entries@topevents.co.za DISPOSABLE TIMING CHIP R 22.00 FAX YOUR ENTRY FORM AND DEPOSIT SLIP TO: 021 510 7230 TOTAL R 167.00 OPTIONAL SPECIAL AGREEMENT MOISTURE MANAGEMENT T-SHIRT R 210.00 The entrant agrees not to hold the Winelands Organising Committee, Helderberg Harriers, WPA, any sponsor, or any person assisting in the organisation or holding Charity donation – DIFFERENCE OF DISTANCE ……………. of the race liable for any injury or illness or loss of property which he/she may suffer directly or indirectly as a result of participating in the race. The entrant TOTAL R______ also confirms that he/she will abide by the rules of the event and that this Special Agreement is entered into for the benefit of the Winelands Organising Committee, Helderberg Harriers, WPA, the sponsors and persons assisting in the organisation and holding of the race. ______________________________ ______________________________ Parent / Guardian if under 18 years Signature
EVENT GENDER I.D. NO AGE ON RACE DAY SURNAME FIRST NAME ADDRESS TOWN / CITY TEL. NO NATIONALITY EMAIL CLUB PROVINCE NUMBER OF COMPLETED WINELANDS MARATHONS AND HALF MARATHONS FULL HALF PERM NO FULL HALF EMERGENCY CONTACT DETAILS NAME RELATION CONTACT NO MEDICAL AID MEDICAL AID NO T-SHIRT NO. COLLECTION FAX ENTRIES DEPOSIT IN FAVOR OF: WINELANDS MARATHON ACCOUNT NAME: BALEKA SPORT MARKETING AND DEVELOPMENT ACCOUNT NUMBER: 1039754767 BANK: NEDBANK BRANCH CODE: 10470900 USE RUNNER’S NAME AS REFERENCE FOR FURTHER ENQUIRIES TEL: 086 005 1021 OR EMAIL entries@topevents.co.za FAX YOUR ENTRY FORM AND DEPOSIT SLIP TO: 021 510 7230 PAYMENT MARATHON (CLUB MEMBERS) DISPOSABLE TIMING CHIP TOTAL MARATHON (NON-CLUB MEMBERS) DISPOSABLE TIMING CHIP TOTAL HALF MARATHON (CLUB MEMBERS) DISPOSABLE TIMING CHIP TOTAL HALF MARATHON (NON-CLUB MEMBERS) DISPOSABLE TIMING CHIP TOTAL OPTIONAL MOISTURE MANAGEMENT T-SHIRT Charity donation – DIFFERENCE OF DISTANCE TOTAL ______________________________ Parent / Guardian if under 18 years R 140.00 R 22.00 R 162.00 R 205.00 R 22.00 R 227.00 R 90.00 R 22.00 R 112.00 R 145.00 R 22.00 R 167.00 R 210.00 ……………. R______ SPECIAL AGREEMENT The entrant agrees not to hold the Winelands Organising Committee, Helderberg Harriers, WPA, any sponsor, or any person assisting in the organisation or holding of the race liable for any injury or illness or loss of property which he/she may suffer directly or indirectly as a result of participating in the race. The entrant also confirms that he/she will abide by the rules of the event and that this Special Agreement is entered into for the benefit of the Winelands Organising Committee, Helderberg Harriers, WPA, the sponsors and persons assisting in the organisation and holding of the race. ______________________________ Signature
WINELANDS-2018-SHOPFAX-ENTRY-FORM-V2.0-1.docx