Entry Form

The Molesworth Run

entry form - Saturday 20 November 2010

Instructions: Print this form, fill it in and mail with payment to:
Mieke Holtrop, Dry Hills Rise, R D 4, Blenheim
Please make cheques payable to: Molesworth Run a/c

Closing date for entries: 13 Nov 2010. Entries with t-shirts 31 Oct 2010.

Solo Eventers Only

Name:____________________________________	Age on race day:_____

Address:_________________________________	Gender (M / F):____

_________________________________________	Grade: please circle one

Phone No. (  ):______________________				Open Men
								Open Women
Email Address:_______________________				Vet. Men (40+)
								Vet. Women (40+)

Details of previous Ultra Distance Events:__________________________________

____________________________________________________________________________

____________________________________________________________________________

Team Event Only

Name (Team Captain):____________________________________
Contact Only

Address:_________________________________

_________________________________________	Grade: please circle one

Phone No. (  ):______________________				Open Men
								Open Women
Email Address:_______________________				Vet. Men (40+)
								Vet. Women (40+)
								Mixed
Leg 1 Runner ______________________________    Leg 2 Runner ______________________________

Leg 3 Runner ______________________________    Leg 4 Runner ______________________________

T-shirts to be announced

please tick numbers and sizes of t-shirts required ...

Short sleeve t-shirts - Men's

Size	Number
XS
S
M
L
XL
XXL
XXXL

Short sleeve t-shirts - Women's

Size	Number
8
10
12
14
16
18
20

To be completed by all entrants:

Entry Fee Run	@ $35.00 per person	_________
T-Shirts	@ $30.00 each	_________
TOTAL:		_________

Waiver - to be completed by all entrants

Please print off the relevant waiver, fill it in and bring it along on race day:

Solo Waiver	2-person team waiver	4-person team waiver
MS-word format 44kb	MS-Word format 44kb	MS-Word format 48kb

Please send entry forms with fee (both race and shirt fees) to Mieke Holtrop, Dry Hills Rise, R D 4, Blenheim.

Alternatively you can pay by internet transfer to account # 12-3167-0051663-00 with references: your name and race category. You still need to mail your entry form with all your details however!