AQUAMAN TRIATHLON 2019 08/12/2019 VENGURLA PARTICIPANT ENTRY FORM Please print out this form, fill each section, scan and email to Organisers at [email protected], after booking your slot and payment of Fees. Booking ID/Registration Reference No. ____________________________ received upon payment of Registration Fees. (Mandatory) 1. Category for entry (Please tick the respective box as per your category): The age cut-off is as per current age on or before 31st August 2019. Aquaman Olympic 12 yrs & above M F Aquaman 70.3 18 yrs & above M F (Half Iron distance) Aquaman 100 Miles 18 yrs & above M F Challenge 2. Name of participant in BLOCK CAPITALS: Master /Ms / Mr / Mrs _______________________________________________________________ 3. Date of Birth (DD/MM/YEAR): ____ /____ /________ Age (as on 31st August 2019): ______ years _____ months. 4. Name of Parent / Guardian (in case of participants aged below 18 yrs): _______________________________________________________________ 5. Relationship with Parent / Guardian: _________________________________ -1- -2- 6. Address: _______________________________________________________ _______________________________________________________________ _________________________________ Pin Code ________________ Phone: _____________________ Mobile: ___________________________ (Please give a mobile number on which any SMS, as and when required, may be sent). 7. Occupation: __________________________________________________________________ 8. Minimum eligibility and previous Open Water Swimming / Run / Brevet / Long distance Cycling certificates for each category: Olympic – The Participant should have successfully finished an Olympic Triathlon OR a 1 Km open water/non-stop 1 km & 1 hr pool swim along with a 10 kms run or non-stop cycling of at least 25 kms in the last one year. Age – 12+ yrs 70.3 Half-iron distance - The Participant should have successfully finished an Olympic Triathlon OR a 2 Kms open water/ non-stop 2 kms & 1.5 hrs pool swim along with a Half Marathon or a Brevet/ long distance cycling of at least 60 kms in the last one year. Age – 18+ yrs 100 Miles Challenge – The participant should have successfully finished an half ironman OR a 2 kms open water swim along with a half marathon or Brevet/ long distance cycling of at least 100 kms in the last one year. Age – 18+ yrs. Please mention event name, year and position. Scanned copy of certificates must be attached with Entry Form. Pool swimmers must attach Letter of Certification from Coach/Instructor attesting that participant can swim Non-stop 1 km/2 kms and 1 hr/ 1.5 hrs in Pool as required in the category. __________________________________________________________________ __________________________________________________________________ -3- 9. Emergency contact person: ________________________________________ Emergency contact number: ________________________________________ 10. Copy of Photo ID showing Date of Birth (no entry will be accepted without photo ID) attached. (Yes / No) _______ 11. Copies of Eligibility Certificates (of previous open water swim/run/brevet/long distance Cycling /pool instructor’s letter) attached. (Yes / No) _______ I, the undersigned triathlete, certify that the above mentioned particulars are correct to the best of my knowledge and I am eligible for the triathlon category opted for by me. Date: ____ /____ /_______ _______________________________ Triathlete's Name & Signature Place: _______________________________________ Parent's/Guardian’s Name & Signature (in case of participants aged below 18 yrs) -4- MEDICAL FITNESS CERTIFICATE Section A - To be filled by Participant Name: _________________________________________________________ Date of Birth: ____ /____ /________ (mm/dd/yyyy) Age: ____________ Gender: Male/ Female Occupation: ______________________________________________________ Address: _________________________________________________________ Town/City: ______________________ Country: ________________________ Post: ____________________________ Pin Code: ______________________ If the answer to ANY of the questions from 1-14 is YES, please attach further details with supporting documents. Have you ever suffered from any of the following? 1. Chest disease, including asthma, bronchitis, collapsed lung or T.B. Yes/ No 2. Attacks of Giddiness, blackouts or fatigue. Yes/ No 3. Fits or nervous disorders - including persistent headaches or concussion. Yes/ No 4. Anxiety, “nerves”, nervous breakdown, panic attacks. Yes/ No 5. Disease of the heart and circulation, including high blood pressure. Yes/ No -5- 6. Ear trouble, earache, discharge or deafness. Yes/ No 7. Sinus trouble. Yes/ No 8. Do you have diabetes? Yes/ No 9. Do you regularly or frequently take any medication or other treatment? Yes/ No 10. Are you currently receiving medical care, or have you consulted any doctor past year? Yes/ No 11. Have you ever been refused life insurance, or failed a medical examination? Yes/ No 12. Do you smoke? Yes/ No 13. Have you attended or been admitted to hospital in the last 5 years? Yes/ No If yes, state the reason: ___________________________________________ 14. Have you undergone a major surgery in last 5 years? Yes/ No Note **SHOULD YOUR MEDICAL STATUS CHANGE FOLLOWING THIS MEDICAL, THE AQUAMAN ORGANISING COMMITTEE MUST BE NOTIFIED. PLEASE MAKE SURE ALL THE SECTIONS ARE FULLY FILLED AND SIGNED.** -6- DECLARATION BY PARTICIPANT I hereby declare that to the best of my knowledge, I am in good general health and have not omitted any information which might be relevant to my fitness to participate in Aquaman Olympic distance / 70.3 Half Iron distance / 100 Miles Challenge Triathlon 2019, Vengurla. I also agree that relevant information about my health may be disclosed to persons directly concerned with my participation in Aquaman Olympic distance / 70.3 Half Iron distance / 100 Miles Challenge 2019 (tick the category applied for) at Vengurla. I am aware that the Aquaman Triathlon 2019, Vengurla is extremely arduous, both mentally and physically. I declare that I will inform the Aquaman Triathlon Organizing Committee of any medical condition that becomes known to me after the presentation of this Medical certificate and before attempting the event. Signature of Participant: _________________________________ (in presence of examining doctor) Date: Signature of Guardian/ Parent: __________________________ (if the participant is below 18 years) Date: Relationship with the participant : IMPORTANT **Please ensure the organizing committee has at least ONE emergency contact number.** -7- Section B - For the EXAMINING DOCTOR __________________________________________ (name of participant) wishes to be examined with a view to checking his/her physical fitness to participate in Aquaman Olympic distance / 70.3 half iron distance / 100 Miles Challenge (tick the category applied for) Triathlon 2019 Vengurla on 08/12/2019, an arduous, physically and mentally demanding Triathlon event. After examination I consider ____________________________________ to be FIT/UNFIT to participate in AQUAMAN Olympic distance / 70.3 half iron distance / 100 Miles Challenge (tick the category applied for) at this point in time/at the time of this examination. _________________________________________ Date: _____ /_____ /2019 (Signature of the examining doctor) Name of Doctor: _____________________________________________________ Address / Stamp: Tel.: _________________________ -8- INDEMNITY BOND I, the undersigned, hereby make an application to participate in the AQUAMAN OLYMPIC DISTANCE / 70.3 HALF IRON DISTANCE / 100 MILES CHALLENGE TRIATHLON 2019 and certify that all the particulars given by me are correct and that I agree to be bound by this undertaking. In consideration of the acceptance of this application, I agree to save harmless and keep indemnified the Organizers and their officials, the Sponsors, agents, representatives, employees and all persons assisting them in this event and all owners and tenants of private property traversed by this event, from and against all actions, claims, cost, expenses and demands in respect of death or injury to myself or any other person or persons or loss or damage to any property including any personal equipment used in this event, if any or otherwise howsoever and not withstanding that the same may have been contributed or occasioned during this event (negligence cannot be atoned), whether owing to failure despite necessary due-diligence and / or requisite consideration / precaution being taken while conducting respective official duty by the organizer or their officials, agents, representatives, employees and all persons assisting them in this event and arising out of unforeseen contingencies. This indemnity shall be binding on my heirs, executors and legal representatives. I declare that I, the undersigned, am medically fit and possess the standard competence necessary for an event of this type, as mandated by the doctor’s certificate, confirming that upon medical examination, I, the undersigned, can withstand the endurance levels. I agree and undertake to abide by the rules and regulations framed for this event including the conditions precedent set out herein and all other rules and regulations, which may hereinafter be framed. Finally, I hereby acknowledge that I am fully conversant with the risk and dangers of a Triathlon, involving Open Water Swimming, in general and this event in particular, which I assume hereby. LIMITATION OF LIABILITY: These Terms and Conditions govern