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CLEVEDON ASC SPLASH & DASH 18TH OCTOBER 2009 1-4PM Name (If Team – Entry 1 Swimmer)_____________________________________________ Address ______________________________________________________________
______________________________________________________________ Postcode ________________________ Telephone Number _______________
Email ________________________ Date of Birth _______________
Age on 31st December 2009 _____ Male or Female _______________ Name (If Team - Entry 2 Runner)______________________________________________
Address ______________________________________________________________ ______________________________________________________________
Postcode ________________________ Telephone Number _______________ Email ________________________ Date of Birth _______________
Age on 31st December 2009 _____ 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: £7.00 (Child) : £12 (18+) : £12 (Total Team)
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: Thursday 1st October, or when entry limit is reached ( 150 entries ). Any enquiries please contact: Fiona Bowen 01275 877412 / 07970736225 or E-Mail; fiona@bowenfamily.me.uk
__________________________________________________________________________ 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. 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: ____________ |