First Name ________________________ Surname ___________________________
Address ______________________________________________________________
______________________________ Postcode_________ Date of Birth ___________
Telephone Number ____________________________ Age on Race Day
________Affiliated Club (or organisation) ___________________________ Sex (M/F) ______
UK Athletics reg.no. _________________ Email address ________________________________
DECLARATION: I declare that I am an amateur according to U K Athletics laws. I understand that I take part entirely at my own risk and accept that the organisers shall not be liable for any injury or illness to my person as a result of taking part, nor for any damage to or loss of property.
Signature _________________________(signature of adult if 16 or under) Date ______________
*{I am enclosing an S.A.E.}/*{I will collect my number on race day} ... *DELETE WHICHEVER DOES NOT APPLY
Fee enclosed _________ Optional additional donation to Lineham Farm enclosed _________
Gift Aid
Please tick the box if you pay UK Income or Capital Gains Tax and you wish Lineham Farm Children's Centre to reclaim the tax on your donation o
NB we can only reclaim on the additional donation, not on the entry fee.
If you require a Sponsorship Form to be sent to you (no obligation) or would like more information about Lineham Farm, tick hereo