MALDWYN HARRIERS LADIES RUNNING GROUP

NAME............................................ M/F................ DATE OF BIRTH

ADDRESS: .

TELEPHONE NUMBER................................ MOBILE...................................................

Contact Number of relative.........................................................................................

Registration Number „.......... „........................ Club........... „.............................................

Any known medical condition.................................. ________________ ................................................................................ ,._

Have you anyone attending the Leisure Centre or running track while attending on a Wednesday night.
If so please state their name and where they will be:.......................................................................

The organisers of this run will not be responsible for any loss or injury to myself or my property while I attend this event. I am medically fit to run and I agree to abide by UKA laws. I declare that I am an amateur runner.

Signed......................................................... Date..........................................................