Name
E-mail
Telephone
Address
City
Postcode
Date of Birth
Age on 2nd May 2010
Sex
Male
Female
Running Club
Doctors Name
Doctors Phone No.
Allergies or medical conditions?
Relevant Experience of long-distance running
I would like to take part as
Part of a pre-formed team (enter details below)
Part of an on-the-spot team (to be assigned later - enter preferred distance below)
A solo entrant (full 66 miles - enter support details below)
IF part of a pre-formed team - please enter
number of people in team (2-6)
IF part of a pre-formed team please enter team
name
IF part of an on-the-spot team please enter
preferred distance
IF a solo entrant please enter support persons
name
I will be carrying a mobile phone with me during
this event
Yes
No
If YES above please enter your mobile phone
number
Please specify mobile phone network
I understand that the organisers shall not be
liable for
any loss, damage or injury arising
from my involvement in this event
I agree
I do not agree
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