SALT Fun Run Series: Entry Form

Participant's Agreement

Please tick to confirm that you have read and accept the participants agreement. (parent or guardian to tick if participant is under 18)

Personal Details :  
Surname:*
Your surname is required.
First Name:*
Your first name is required.
DOB: (dd/mm/yyyy) *
Your DOB is required.
Age: (at 19/08/2012) *
Gender:*
 
Address *

A value is required.
City/Suburb:*

A value is required.
Post Code:*

A value is required.
Country: (if not Aust.)
   
Phone Contact:*

A value is required.
Email:*

A value is required.Invalid format.
Confirm email:*

A value is required.Invalid format.
   
Medical Conditions
See item #10 :

Are you part of a running or athletics club?

No
Yes - enter my team in the draw to win!


Are you staying at either Mantra or Peppers at SALT the weekend of the race?

No
Yes - enter me in the draw to win!

Stay the night before at either Peppers Salt Resort or Mantra on Salt Beach, both are
convenient Kingscliff Accommodation choices
   
Race Selection:

  • Mantra 10km races
    $30 for 1 race or $50 for both races.
    Children under the age of 16 can still enter the 10km race in the 16-19 category if they wish.
  • Peppers 5km races
    $25 for 1 race or $40 for both races.
    Children under the age of 11 can still enter the 5km race in the 11-12 category if they wish.
  • Junior Dart races
    $10 for 1 race or $20 for both races.
    For kids 10 years and under.
I wish to enter*:
  • You must select a race.
  • For multiple race entries please register separately.

 

  Total payable $   inc GST.

 

Payment Details:
Payment may be made by MasterCard or Visa.  I hereby authorise the following debit to my credit card in favour of Corporate Challenge.
Card Type: Please select an item.
Cardholders Name:
A value is required.
Card Number:
A value is required
Expiry Date: /  (enter as mm / yy)
CVV:
(3 digits on back of card)