Healthways Beverley Triathlon Entry Fees Junior Individuals Junior Team Open Individual Open Team Entry Form Name: $15 $45 $20 $60 Date of Birth: Age: Phone Number: Mobile Number: Email: Address: Entry Forms available from: Beverley CRC office Online at www.beverley.crc.net.au Beverley Swimming Pool Saturday 21 March 2015 Beverley Swimming Pool Nippers (9 years and under) 50m Swim / 1.2 km Bike / 600m Run Juniors (13 years and under) 100m Swim / 2.4 km Bike / 1 km Run Short (14 years and over) 200m Swim / 8 km Bike / 3 km Run Long (14 years and over) 400m Swim / 16 km Bike / 6 km Run 7.00am - Register for Nippers 7.30am - Race Briefing for Nippers 8.00am - Race Start for Nippers Registration times, race briefing and race start times for Juniors and Open will be confirmed one week prior to race day and sent to you upon receipt of your registration. Emergency Contact Details Contact Name: Contact Number: How to Register Fill out this form and return to PO Box 310 with your payment prior to Wednesday 18 March 2015. How to Pay By Electronic Funds Transfer Account Number: 253066884 BSB Number: 016540 Details: Surname and include TRI15 Please email remittance advice xxxxx@westnet.com.au to By Mail Cheques written and posted to Beverley Community Resource Centre Inc, PO Box 310 Beverley WA 6304 In Person At the Beverley CRC - 132 Vincent Street. Office opening hours - Monday to Friday 8.30am to 4.00pm. Cash or cheques accepted. Please note that we do not have credit card or EFTPOS facilities. Relationship: Medical Information (include allergies) Tick Category Nippers Junior Tick Division Individual Short Long Team (please complete below information) Team Details Team Name: Swim - Competitor Name: Cycle - Competitor Name: Run - Competitor Name: Please ensure you have read and signed the terms and conditions and participant signature and date as this forms part of the registration. Terms and Conditions of Entry Please read this acknowledgement, waiver and release from liability carefully before continuing with your entry. In registering for the Beverley Triathlon I agree to the following terms and conditions: 1. I/we the undersigned in consideration of, and as a condition of acceptance of my entry in the Beverley Triathlon (the event) for myself, I/we hereby waive all and any claim, right or cause of action which I/we might otherwise have arising out of my death or injury, damage or loss of any description whatsoever may suffer or sustain the course of, or consequent 2. am in good physical health and am participating in the Beverley Triathlon at my own risk. 3. Neither the Beverley Community Resource Centre Inc, nor its committee members, employees, agents, contractors, sponsors, volunteers shall be liable for any loss or damage whatsoever caused to me arising out of or contributed to by my participation in the event, including any loss or damage that may arise out of negligence of any of the parties as mentioned above. 4. entrant is under 18, certify that am the parent/ legal guardian of and he/she has my consent to participate in the Beverley Triathlon. 5. This waiver, release and discharge shall be (and operate separately) in favour of all persons, corporations and bodies involved, or otherwise engaged in promotion or staging the event and each of their servants, agents, representatives and officers. 6. Under no circumstances will a refund be provided. 7. All medical information must be declared. The medical questions have been answered truthfully and I/we acknowledge that I/we should seek medical advice prior to participating in the event if I/we have suffered or I/ we am/are suffering from a medical condition or injury. Event Sponsors: 8. Consent to medical treatment: I/we consent to receiving any medical treatment that the event organisers or their authorised representatives consider necessary or desirable during or after the event. 9. I/we give permission for the free use of my name, voice or picture in any broadcast, telecast, advertising, promotion or other account of this event, including advertising and promotions for future Beverley Community Resource Centre Inc events. 10.I/we agree to read the event rules and regulations and conform to them. 11.Privacy Statement: The Beverley Community Resource Centre Inc respects and values the privacy of all information we collect about event participants. As the event organiser, we collect information about participants for the administration and conduct of the event. Information collected will be securely stored on our database. It will be disclosed to medical staff for delivering medical services and participant names to the newspaper for publishing participant's times. Participant's information may also be given to our public relations consultant for generation of media stories with prior consent. By entering this event, you consent to your personal information being provided to the Beverley Triathlon event organizer for administration and conduct of the event. I have read and agree to the terms and conditions of the Beverley Triathlon 2015. I have read and agree to the waiver and release from liability of the Beverley Triathlon 2015. I authorise event personnel to administer first aid in the event of an emergency. Participant Name: Participant Signature: Date: Office Use Only Date: Payment Received: $ Cash Cheque Registration Form Signed: EFT Yes Registration Officer Only Race Rules Sent: Wave Allocation Time: Yes No No