Gallipoli Run registration form for 2009 by alendar

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									Synergy
Gallipoli Run.
Sunday 19 April 2009. Synergy Parkland,
Kings Park. Starts 9am.




Run or walk to commemorate
the ANZAC spirit.
The Synergy Gallipoli Run is a special event held
annually in recognition of the ANZAC spirit.
Held on Sunday 19 April at Synergy Parkland, Kings
Park, this event caters to both runners and walkers
alike with three options available – an 8km (5 mile)
run, a 4km run or a 4km walk.
Take part and also improve your health and fitness as
we raise money for Athletics WA and the RSL.
To enter, please complete and return the entry form
overleaf, or enter online at synergy.net.au/gallipoli
Entry form
Complete and return to Athletics WA or enter online at www.waathletics.org.au

Event entered:                    8km run                            4km run                          4km walk

Last Name                                              First Name

Gender                                                 Age

Address

Suburb                                                 State                       Postcode

Phone                                                  Email

•	Competition bib numbers to be collected at check in from 7.30 to 8.30am.
•	Bag	storage	area	provided	near	start	area,	but	leave	at	your	own	risk.


  Entry fees                     (non refundable)

  Entry fees are tax deductible. Receipts will be posted on request.
  	                                                                         By	16	April	                On	the	day
  Adult                                                                            $15                        $20
  Concession	(under	18,	65+,	student)	                                             $10	                        $15
  Family (2 adults & 2 concessions)                                               $40                          n/a
  (Family entries must be entered together and the entry fee paid with a single payment.)

  Entry fee                                   Donation                                   Total

  Paying by:                     Cheque                   Money Order                         Credit Card*
  Please post me a receipt
  Make cheque/money order payable to Athletics WA and mail to:
  Athletics	WA,	PO	Box	157,	Floreat	Forum,	WA,	6014.	
  Or deliver in person to: Athletics WA Office, Perry Lakes Stadium.
  *If paying by credit card please visit www.waathletics.org.au



Waiver               (If you are 17 or under this part must be signed by your Parent or Guardian.)


I certify that I am the Parent/Guardian of

who is                 years of age and that he/she has my consent to run in this

event, and I hereby join the indemnity below:

Signature (Entrant/Parent/Guardian)                                                         Date
1. I have read the conditions of entry for this event and understand the demanding physical nature of the event. I have
trained for this event and I am not aware of any medical condition or impairment that will be detrimental to my health if
I participate in this event. In the event that I become aware of any medical or impairment, or am otherwise sick or injured
prior to the event, I will withdraw from the event. 2. I acknowledge that participating in this event may involve a real risk
of serious injury or even death from various causes including; over exertion, dehydration, and accidents with other
participants, spectators or road users. 3. I acknowledge that it is a condition of participating in this event that I do so at
my own risk. I accept all risks and release the event organiser, its agents, affiliates, employees, members, sponsors,
promoters, volunteers, and any person or body, directly or indirectly associated with the event, from all claims, demands
and proceedings arising out of or connected with my participation in this event and I indemnify them against all liability
for all injury, loss or damage arising out of or connected with my participation in this event. This release continues forever
and binds my heirs, successors, executors, personal representatives and assigns. 4. I consent to the publication and/or
use in any form of media whatsoever of my name, image, voice, statements or otherwise, before, during or after the
Event whether for advertising, promotion or otherwise, without payment or compensation. 5. I agree that should the
Event be cancelled for any reason whatsoever, my entry fees will not be refunded and no liability of any kind whatsoever
will attach to the Organisers.
    I do not wish to receive athletics related information from Athletics WA.

								
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