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ENTRY FORM

Delete as appropriate:

MALE / FEMALE

HALF MARATHON / FUN RUN

Surname:

Address:

Tel. No.:

Affiliated Club:

Estimated Time:

Forenames:

Date of Birth:

Regional Membership No:

Age on Race Day:

DECLARATION:

I am medically fit and understand that I enter at my own risk. The Organisers will in no

way be responsible for any injury or illness incurred as a result of the event, nor for any

property lost or stolen before, during, or after the event.

SIGNATURE:..........................................................

DATE: .............................

Tick Box to enter the Derbyshire Championships.

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Return this form to:

Eric Lane, 24 Craigston Road, Carlton in Lindrick, Worksop,
Notts S81 9NG (Tel: 01909 730652) by Monday 17th November,
with a cheque made payable to Clowne Road Runners, and
include a 9" x 4" S.A.E.

Visit our website: http://www.clowneroadrunners.co.uk

Clowne Road Runners would like to thank the following sponsors for their much appreciated

help in organising this event:-

Buckingham Insurance, 01246 570600

David Slater Insurance, 01246 819443

Bolsover Caravans, 01246 828303

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COUNTY

QUALIFICATION

(ie. Birth/Residence

HMF. Please state)

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IF YOU DO NOT TICK THE BOX AND INSERT "BIRTH" OR "RESIDENCE"

YOU WILL NOT BE ENTERED INTO THE CHAMPIONSHIPS. NO LATE
ENTRIES ACCEPTED

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If you have any medical conditions please give details ...............................................................

All details are covered by the Data Protection Act.

Shires Pharmacy, 01246 810360

B Kinsey Builders, 01246 812200

Ibis Hotel, Barlborough, 01246 813222

To enter this part of the race you must either live

in Derbyshire or have been born in Derbyshire

Chris Edwards Charted Accountants, 01246 570581