Surname:      

Forename(s):

Address:       

                      

                      

                      

Postcode:                  Telephone:   

UKA Affiliated Club:          

Age on Race Day (min 17yrs):           Date of Birth:             England Athletics Reg. No.:

Male/Female:                  Email:  

                                                                               

Entry Fee: £11 Affiliated     £13 Unattached      (£2 extra on day)
Cheques made payable to: Pewsey Vale Running Club

Declaration: I understand that I take part in this event entirely at my own risk, and that no person(s) or organization(s) will be held responsible for any accidents, injury, illness, loss or damage that may arise as a result of my participation. I declare that I will abide by UKA rules and the directions of the organizer's representatives. I understand that the organizers reserve the right to delay or cancel the event should adverse weather conditions or other circumstances outside of the organizers control pose an unacceptable risk to the participants. On the date of the event I will be the minimum age of 17 or older.
Entry fees are non-refundable and non-transferable, even in the event of cancellation.

Signed: ________________________________________________

Date:____________________________

Please send completed form and cheque to Race Secretary:
Richard Pearce, The Old Orchard, Rudge Lane, Oare, Marlborough, Wilts SN8 4JH (Phone 01672 562412).

Include 9x4 self-addressed stamped envelope.