tough guy and gal challenge EXTREME OFF ROAD RUNNING EVENT

EVENT NO: (official use only) Use the buttons on the right to clear the form, print a copy, or email it to the event organisers X P @ EVENT VENUE & DATE (Please Tick)

*WELLINGTON Saturday 25th May AUCKLAND Saturday 29th June *HAWKE’S BAY Sunday 28th July

*HAMILTON Saturday 8th June *AUCKLAND Sunday 30th June *PALMERSTON NORTH Saturday 3rd August

* Corporate / Gym Club Challenge option available *ROTORUA Saturday 24th August

EVENT DISTANCE (Please Tick) 6km Event 12km Event COMPETITOR DETAILS

First Name Date of Birth Must be completed for Grade placement Last Name Gender Postal Address Phone Mobile Phone Emergency Contact Emergency Phone

Email Address For E-ticket confirmation

Team Name For Corporate Gym / Club Challenge EVENT FEES WELLINGTON 1st Feb - 1st May $67.50 HAMILTON 1st Feb - 1st May $67.50 WELLINGTON 2nd May - 13th May $72.50 HAMILTON 2nd May - 27th May $72.50 WELLINGTON From 14th May $85.00 HAMILTON From 28th May $85.00

AUCKLAND 1st Feb - 1st May $62.50 HAWKE’S BAY 1st Feb - 1st May $62.50 AUCKLAND 2nd May - 17th June $72.50 HAWKE’S BAY 2nd May - 15th July $72.50 AUCKLAND From 18th June $85.00 HAWKE’S BAY From 16th July $85.00

PALMERSTON NORTH 1st Feb - 1st May $67.50 ROTORUA 1st Feb - 1st May $67.50 PALMERSTON NORTH 2nd May - 22nd July $72.50 ROTORUA 2nd May - 12th August $72.50 PALMERSTON NORTH From 23rd July $85.00 ROTORUA From 13th August $85.00

EVENT MERCHANDISE MULTI-EVENTS & BULK ENTRIES Women’s T-shirt S M L XL XXL $35.00 Corporate or Gym/Club Team. Each team must have a minimum of five team members all competing in the 6km event. There is Men’s T-shirt S M L XL XXL $35.00 no maximum number of team members. Standard or bulk entry fees apply. Unisex Hoodie XS S M L XL XXL $60.00 Have a group of 20 or more people? You can apply for our bulk Beanie $20.00 entry discount. Sports Cap $20.00 Want to do 2 or more events? A multi-event discount is availabe. The more events you enter the more you save. Sweat Band $10.00 Please email [email protected] for more information on any of the above. Sports Bag $40.00 Entry Fee Total Pilsner Stemmed Glass $15.00 Merchandise Total Drink Bottle $10.00 Cure Kids Donation Enter Amount TOTAL $ tough guy and gal challenge

PAYMENT OPTIONS (Please Tick)

Online Bank Deposit. Entry must be accompanied by proof of deposit. Online Deposits to: Please use your full name as a reference. ASB Taupo 12-3162-0075818-61 Event Promotions

Cheque: Please make cheques payable to: Tough Guy & Gal Please post entry & cheque to: Event Promotions, PO Box 324, Rotorua 3040

GST No. 62-658-398

MEDICAL DECLARATION (Please list any existing medical conditions)

WAIVER AND RELEASE STATEMENT (All competitors must sign their Waiver and Release Statement) In consideration of the acceptance of my / our entry for the event, I hereby waive, I confirm, where this entry is completed on behalf of me and/or others, that these release and discharge Event Promotions Limited, its director/s and staff, owners and/ others have been made aware of the above statement and that each of them confirm or custodians of land and property on and over which the event is being conducted, the waiver, release, discharge and indemnity set out therein, including on behalf of event sponsors and promoters, suppliers of product and services (including medical their executors, administrators and assigns. services), volunteers and volunteer groups, and all other persons, entities or groups associated with the planning and conduct of the event (individually or collectively Refund Policy referred to as the “indemnified parties”), from any liability and claims that arise from No refunds will be given within 7 days of each event - no exceptions. losses, injuries and or damage however caused (whether fatal or otherwise) that A $10.00 fee per person will apply prior to this date. I may suffer from my preparation for and/or participation in this event. Further, I hereby indemnify and hold harmless the above described “indemnified parties” from all actions, suits, proceedings, claims, demands, losses, damages, penalties, fines and other financial impositions however arising. This waiver, release, discharge and Signed: (Signature of entrant, guardian if under 18 years). Print name. indemnity is provided for me, my executors, administrators and assigns. I agree to comply with the rules of the event and will compete entirely at my own risk. I authorise the use of my name, voice, picture and any information provided by me on this entry form, and without payment, for the purpose of any broadcast, telecast, communication, promotion, advertising or activities associated with the current or Date: future events or other events promoted by or on behalf of Event Promotions Limited. I acknowledge that if the event is cancelled due to acts of nature, my entry fee will not be refunded.

EVENT ORGANISED BY

Enter online at: www.eventpromotions.co.nz Phone 07 348 3301