Entry Form - Microsoft
4772025-400050WESTERN PROVINCE MASTERS ATHLETICS CHAMPIONSHIPS 2019 Entry FormDate: 13 April 2019Venue: Green Point Athletic StadiumEntries Close: 7 April 2019Only Masters athletes (30 years and older) may enter these ChampionshipsNo late entries will be acceptedFull Name:________________________________________________________________________________________ Gender: M FAddress:____________________________________________________________________________________________________________Address:__________________________________________________________________________________________Code: ___________ Tel:___________________________ Date of Birth:_____/____/_______19Cell:___________________________________ Email Address:____________________________________________________ Province: ______________________________ASA Lic. no: __________________________________ Age Group:_______________Athletes must wear provincial licence numbers. No restriction on number of events. Medals to first 3 in each age group.Please Note: 10 & 20 km Race Walking events will be hosted on 11th May 2019 @ Youngfield although entries for these events needs to be entered below.Office UseOffice UseEventMedalSignatureEventMedalSignature15263748I declare that my date of birth is correct. That I take part at my own risk and that I shall not hold the organizers responsible for any occurrence that may arise from my participation and that I will abide by the rules set by S.A.M.A./A.S.A. AND W.M.A. / I. A.A.F. applicable.Ek verklaar dat my geboortedatum korrek is. Dat ek op my eie risiko deelneem. Dat ek nie die organiseerders aanspreeklik hou vir enige gebeurlikheid as gevolg van my deelname nie en dat ek my neerlê by die reels so vereis word deur S.A.M.A./A.S.A. (EN W.M.A. / I. A.A.F. WAAR VAN TOEPASSING.Athlete’s signature / Atleet se handtekening :_____________________Date / Datum :___________________Queries: Banking Details:Entry Fee:Leza BuckleContact no:072 182 7723Acc. Name: WP Masters Athletics Bank: ABSA Cheque Account1st Event : R50 x 1 = R50Thereafter: R40 x________ = R_____Total: = R __________Email entry & deposit slip to:Branch: Parow 502-110Acc. No:0390179839ALL MONIES TO BE PAID IN ADVANCEwpamasters@I M P OR T A N T I N F OR M A T ION :Proof of payment/deposit slip must reflect your initials and surname as a reference.2019 ASA Licence numbers (i.e. Provincial numbers) must be worn on the front and back of the vest.Report to Masters Registration upon arrival and please ensure you are ready for participation in your event at least 30 minutes before the designated time.Athletes 80 years plus only pay R50 entry fee regardless of number of events.Honorary Life Members of WPA : Masters – no charge.Contact persons: Leza BuckleCell: 072 182 7723Email: wpamasters@OR Robert Buck Cell: 084 902 4917Email: bbuck@mweb.co.zaTHESE CHAMPIONSHIPS WILL BE HELD IN ACCORDANCE WITH THE RULES AND REGULATIONS OF S.A.M.A./A.S.A. (And W.M.A. / I.A.A.F. WHERE APPLICABLE) ................
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