| Entry Date : |
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| Yellow Chip Code : |
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Please fill in your yellow chip code if you have one. If not, put dash ("-") in this field. We will provide you with a chip for the race. |
*Category : |
Male 12 years & Above
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Female 12 years & Above |
| * Given Name: |
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| * Family Name: |
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| * Nationality: |
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| *Gender: |
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| *Date Of Birth : |
-
-
(dd - mm - yyyy) |
| *Age : |
(Age on 7 December 2008) |
| *T-Shirt Size : |
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| *Address 1 : |
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| Address 2 : |
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| Suburb : |
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| State / Province : |
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| *Postal Code : |
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| *Country of Residence : |
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| *E-mail (First priority) : |
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| *Confirm E-mail (First priority) : |
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| Second E-mail : |
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| *Business Phone : |
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| *Direct Line : |
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| Private Phone : |
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| *Mobile : |
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| Facsimile : |
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| *Occupation : |
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| *Emergency Contact Person 1 : |
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| *Emergency Contact Telephone 1 : |
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| Emergency Contact Person 2 : |
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| Emergency Contact Telephone 2 : |
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| Overseas Airline : |
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| Hotel in Phuket : |
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| Domestic Airline : |
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| Significant Athletic Accomplishment or Interesting Personal Story : |
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| Do you have any current medical problems or conditions for which a doctor is treating you ? |
Yes
No |
| Details : |
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| Are you allergic to any medications ? |
Yes
No |
| Details |
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| Do you wish the event medical staff to be aware of any specific medical problem ? |
Yes
No |
| Details : |
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| Remarks : |
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I certify that I am medically fit to complete and fully understand that I enter at my own risk, and the organizers will in no way be held responsible for any injury, illness of loss, during or as a result of the event. |
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