Saturday 21 March 2015 - Beverley Community Resource Centre

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