The Molesworth Run

entry form - Saturday 19 November 2011

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: 12 Nov 2011. Entries with t-shirts 31 Oct 2011.

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 singlets required ...

Tech fabric singlet with classic logo - Men's

Size	Number
S
M
L
XL
XXL
XXXL

Tech fabric singlet with classic logo - Women's

Size	Number
8
10
12
14
16
18

---

To be completed by all entrants:

Entry Fee Run	@ $40.00 per person	_________
Singlets	@ $35.00 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!