MIC MORRIS MEMORIAL RUN by v8F6UR

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									                                                                                          Certificate No: WAE 036

                                                                                                Race Permit No: WL 2010069


             MIC MORRIS MEMORIAL SPORTING TRUST
                                                                    (Charity Reg no: 519636)



                                                        TORFAEN 10K:
                                                   SUNDAY, 5 DECEMBER 2010
                                                                                                                Office use only
                                                                    ENTRY FORM                                  No _________

  Please complete the following, ticking ( ) boxes where applicable.

  Surname _____________________________ Christian Name(s) _________________

  Address _______________________________________________________________

  ________________________________________________ Postcode ______________

  Date of Birth __________________________ Age ______ Sex : M                                                   F

  Are you registered as a person with a disability? Yes/No*
   (*Delete as appropriate)

  Name of Club ____________________                                                  Reg no    _______________________

  Please tick the box if you require transport at a cost of £3.00. This will take you from
  Pontypool Active Living Centre car park to the start of the race.

  Entry fees: £8.00 affiliated £10.00 unattached (additional £2.00 on day)
  All runners will be classed as unattached unless they are registered with their athletics
  board (eg AAW). Transportation details will be forwarded with race numbers, route
  details, etc.

  NB:            (i)             Entrants MUST be aged 17 years or over on day of race.
                 (ii)            Last postal entry 17 November.
                 (iii)           Full set of results will be sent to all participants on request.


  I enclose entry fee of £ ________ and transport fee of £3.00                                       (tick if required)

  Please make cheques payable to “Mic Morris Memorial Sporting Trust”

  Entry forms/fees returnable to: Christine Philpott, Administrative Assistant, Torfaen
  Sports Development, Level 3, County Hall, Cwmbran NP44 2WN
  Tel: 01633 628936 Email: christine.philpott@torfaen.gov.uk




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                                                                                              Certificate No: WAE 036


                                                                                        Race Permit No: WL 2010069




                                                          TORFAEN 10K
                                  In support of the Mic Morris
                                    Memorial Sporting Trust
                                                                    (Charity Reg No 519636)



                                  (ACCURATELY MEASURED COURSE)


                   SUNDAY, 5 DECEMBER 2010
                                             All profits from the Race will be donated to the
                                                Mic Morris Memorial Sporting Trust Fund

                                               Start at 10.00 am Cwmavon Road, Blaenavon
                                                           Finish: Pontypool Park

                                                      Suitable for all athletes with disabilities

                                              Entry Fees: £8.00 affiliated £10.00 unattached

                                         Entries on the day: an additional £2.00 surcharge

                                                      Transport is available at a cost of £3.00



                           Entry by official entry form available from Cwmbran Stadium,
                           Pontypool Active Living Centre and Fairwater Leisure Centre

                                                                  or by post/email from:

                                                             Christine Philpott: 01633 628936
                                                             christine.philpott@torfaen.gov.uk




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