Entry Form Headway Hustle 2014 (1) .pdf

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Original filename: Entry Form Headway Hustle 2014 (1).pdf
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61 Canal Street
Derby
DE1 2RJ
Tel. 01332 298577
Email: mail@headwayderby.org
www.headwayderby.org

ENTRY FORM
‘Headway Hustle’
20th Anniversary Event - 4.1 measured multi terrain parkland & tarmac surface
Start & Finish at Derby Rugby Club, Haslams Lane, Derby DE22 1EB
Sunday 6th July 2014 – Race start 11am
PLEASE COMPLETE IN BLOCK CAPITALS
Surname

First Name

Club

Address …………………………………………………………………………………………………………………….
………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………
Post Code

Home tel.no.

Email

Date of Birth

Age on Day of
Race

M/F

Age Group

Nationality

Total Fee Enclosed £

Signed

Date

o

I declare that I am an amateur as defined by UK Athletics rules

o

I agree to abide by the current UKA rules of competition.

o

I agree not to hold the promoter / promoting body responsible in anyway for injury or loss resulting from my
participation.

Entry Fee: £12 Affiliated athletes £10 quote National Association Registration No. …………………………………………..
To: Mrs Joy Walsh. 32 Wade Drive Mickleover Derby DE3 9BS (enclose A5 SAE)
Closing Date: Monday 30th June 2014
Cheque payment to ‘Headway Derby’ or contact mail@headwayderby.org for BACS payment details

Registered Charity No. 1107803, Company limited by guarantee

Supporting 'Headway Derby' is now simple – text ‘HWDY01 £2/£5/£10’ to 70070 and instantly
donate in support of brain injury survivors and their families and carers locally.


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