Channel Challenge Entry Form 2018

Channel Challenge

Entry Form

Sunday 25th March 2018

at West Winds Community Centre
3528 Channel Highway, Woodbridge 7162

8.30am for 9.00am staggered start

Entry Fee: $10/person (pre-register) or $15 on the day.

Pre-registrations close 3pm Friday 16th March 2018.

Registrations on the day MUST be at West Winds Community Centre by 8.00am.

Entry is open from 8 years to adult.

Full Name*

First NameLast Name

Age (if 18 and under)

Address*

Street Address

Street Address Line 2

Town

Postcode

E-mail*

Phone Number*

Area CodePhone Number

Categories:

Competitive Adults - This category is for competitive adults. (4 km course)

Competitive Children - This category is for competitive children under 18 years. (4 km course)

Challenge - This category is for all ages, suited to those looking for a bit of a challenge. (3 km course)

Cruise - This category is for all ages, e.g seniors, parents with children. (3 km course)

Please select category*

Competitive - AdultsCompetitive - ChildrenChallengeCruise

Parental Permission for under 12 years of age required.

Yes, I give my child permission to enter

Liability Disclaimer / Indemnity

I understand and acknowledge that participating in the Channel Challenge event is a potentially hazardous activity. There may be unmarked trip and/or slip hazards. I am aware of the hazards involved and hereby assume full responsibility for any and all damages, injuries, or losses that I/my child may sustain or incur, if any, while participating in the Channel Challenge.
I acknowledge that I/my child have/has sufficient fitness, competence and experience to participate in this activity in a manner safe to myself and others and have not been advised otherwise by a qualified medical person that I/my child cannot participate in the challenge.
I acknowledge that I am responsible for my child during the Challenge.
I give my consent for me/my child to receive any first aid and medical treatment which may be deemed advisable in the event accident, injury and/or illness occurs as a result of my/my child’s involvement in the Challenge.
I acknowledge I am responsible for my personal accident insurance and ambulance cover.
I acknowledge that the organisers reserve the right to reject any entry without having to justify their actions.
I indemnify and shall keep indemnified West Winds Community Centre for any actions, injuries, claims for injuries, demands, damages and/or other entitlements which I/my child may suffer now or in the future from my/my child participating in the Channel Challenge.

Do you agree to these terms and conditions?*

YesNO

Media Consent

I hereby consent to the collection and use of my/my child’s personal images by photography or video recording in relation to the Channel Challenge at West Winds Community Centre on Sunday 25th March 2018.

I acknowledge these images may be used on the West Winds Community Centre website, in newsletters and media publications. I give this consent voluntarily.

I understand that my consent can be withdrawn at any time in writing to the Director at West Winds Community Centre.

YesNo

Payment Information

Please put your surname and CC (Channel Challenge) in the 'To' field so we can identify the payer. Copy the bank details below as you won't have access to it after you submit your form.

Direct Deposit

Name: West Winds
BSB: 633 000
Acc: 142101872

Please select payment option*

Direct Deposit ($10)Pay on the Day ($15)

How did you hear about this event?