CLEVEDON ASC SPLASH & DASH 17TH OCTOBER 2010 1-4PM
Name (If Team – Entry 1 Swimmer)_____________________________________________
Address ______________________________________________________________
______________________________________________________________
Postcode ________________________ Telephone Number _______________
Email ________________________ Date of Birth _______________
Age on 31st December 2010 _____ Male or Female _______________
Name (If Team - Entry 2 Runner)______________________________________________
Address ______________________________________________________________
______________________________________________________________
Postcode ________________________ Telephone Number _______________
Email ________________________ Date of Birth _______________
Age on 31st December 2010 _____ Male or Female _______________
Estimated time for swim section (entrant 1) _______________
Medical details we should know about ( ie. Asthma ) ___________________________
Please note: Due to the nature of the team event and the logistics involved we will not be able to present 1st/2nd and 3rd places to team entries – but you can still have fun! _______________________________________________________________________
Entry Fee: Non ASA Members £8.00 (Child) : £14 (18+) : £20 (Total Team). Fee includes club category membership.
Entry Fee: ASA Members £6.00 (Child): £12 (18+): £17 (Total Team) ASA Membership No ____________
Please make cheques payable to Clevedon ASC
Please return entry form along with entry fee and an SAE to:
Fiona Bowen, Rose Cottage, Nortons Wood Lane, Clevedon, BS21 7AE
Closing Date: Friday 1st October, or when entry limit is reached ( 150 entries ), or enter on the day £2 extra
Any enquiries please contact: Fiona Bowen 01275 877412 / 07970736225 or E-Mail; fiona@bowenfamily.me.uk
__________________________________________________________________________
Competitor Agreement:
I declare that I am fit to take part in this event and understand that I take part entirely at my own risk. I accept that the organisers will not be held responsible for any injury , loss or damage sustained to either my person, or my property during the event as a result of my participation.
Signature _______________________________ Date ______________________
Parental / Guardian Agreement: (For children under the age of 18)
I declare that my child is fit to take part in this event and understand that they take part entirely at their own risk. I accept that the organisers will not be held responsible for any injury , loss or damage sustained to either my child, or their property during the event as a result of their participation.
I agree to my child competing and I declare that I, or another adult will be present during the event.
Signature _______________________________ Date ______________________
Consent for Photographs (For children under the age of 18)
Photographs may be taken at the Clevedon Splash & Dash by local press and other participants / supporters.
The photographs may be used by the event organisers for publicity material such as press releases, TV, media and promotional displays.
I hereby grant Clevedon Splash & Dash organisers the absolute right to use images resulting from photography at the event. This includes any reproductions or adaptions of the images for all general publicity purposes.
Signature of Participant _______________________ Date: ____________
Signature of Parent/Guardian ___________________ Date: ____________