8/14/2019 Great South Run 2009 Registration Form Please Complete Each

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Great South Run 2009

Registration FormPlease complete each section fully and in BLOCK CAPITALS

Personal Details

Full Name:________________________________________________________________________________________________

D.O.B : ______________________________________________________________________________ Gender: M / FEmail: ________________________________________________________________________________________________________________________________________________________________________________________________________________

Home Telephone: _______________________________________________________________________________________

Mobile : __________________________________________________________________________________________________Address: _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

_____________________________________________________________ Postcode:___________________________________

Next of Kin (in case of emergency)

Name: ___________________________________________________________ Relationship: ________________________

Address: _________________________________________________________________________________________________

_____________________________________________________________ Postcode:___________________________________Home Telephone: _______________________________________________________________________________________

Mobile : __________________________________________________________________________________________________

What size running vest do you require? : Small Medium Large Extra Large

Payment Details

I enclose a cheque for _______________ payable to Wessex Heartbeat (Registration Fee: 30)Or

Please debit my Visa/Mastercard/Switch/Maestro/Amex Card No:____________________________________________________________________________________________________________

Start date: _____________ Expiry date: ______________ Issue no. (switch/maestro): ______________Card security no: ______________ (3 digits) Amount to be debited: ___________________

Signature: ________________________________________________________________________________________________

Recommend a friend help us find new runners!

If you know someone who you think would be interested in joining you and running the 2009

Great South Run for Wessex Heartbeat, please fill in their details and we will send theminformation about taking part.

Full Name:________________________________________________________________________________________________Email: ____________________________________________________________________________________________________

Address: ______________________________________________________________________________________________________________________________________________________________ Postcode:___________________________________

8/14/2019 Great South Run 2009 Registration Form Please Complete Each

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I, _____________________________________, would like to take a place in the

2009 Great South Run on behalf of Wessex Heartbeat.

I accept that if I take one of Wessex Heartbeats places that:

1. I understand that this guaranteed entry place has cost Wessex Heartbeat 44. In order to cover the

cost of my place and to support the charitys work, I agree to raise a minimum sponsorship target of100 for Wessex Heartbeat.

2. I agree to pay a non- refundable registration deposit of 30

(NB In the event that you should cancel your Wessex Heartbeat guaranteed entry place, the charity

reserve the right to retain your deposit as an administration fee)

3. I agree to make up any shortfall of my sponsorship target personally.

4. I agree that any money raised in sponsorship in the name of Wessex Heartbeat must be forwarded

onto the charity.

5. Participants enter the Great South Run at their own risk. I declare that I am in a suitable physical

condition to undertake the necessary training for and participate in the run and I agree to seek expert

medical advice if I have any health concerns prior to the race. By providing me with a guaranteed entryplace, Wessex Heartbeat is in no way responsible for my fitness and ability to complete the course, or

for any injuries I may sustain in training or during the race.

6. Wessex Heartbeat or its employees do not accept responsibility for loss or damage to personal

property, personal injury (or death) or any claim arising from the entrants own actions.

By signing below, I confirm that I have read and agree to the Terms and Conditions stated above.

Signed________________________________________________ Date __________________________

Please sign and return to:

Melody Carter, Fundraising Co-ordinator, Wessex Heartbeat, PO Box 270, Southampton General

Hospital, Southampton, Hampshire, SO16 6GE. Any questions: info@heartbeat.org.uk

Registered Charity No: 1116510. Company Limited by Guarantee No: 5924982

GREAT SOUTH RUN 2009

TERMS AND CONDITIONS

Thank you for taking the time to fill out this form. The details completed on this form, including your email address/mobile

number, may be used to keep you informed about Wessex Heartbeat and our future events.

If you do not wish to receive such information by any of the methods listed below please indicate by ticking the

corresponding box:Post Email Telephone SMS

All the data in this form will remain CONFIDENTIAL.