SDGG - 10 KM Run 2012

ENTRY FORM DATE FLAG OFF TIME VENUE (START/FINISH) CLOSING DATE : : : : 28 APRIL 2012 (Saturday) 7.30 am BUKIT JELUTONG, SALES GALLERY 18 APRIL 2012 (Wednesday)

FULL NAME (BLOCK LETTER)

I/C NO

SEX MALE

DATE OF BIRTH

AGE

FEMALE

TELEPHONE NO.

POSTCODE

MAILING ADDRESS

SAP NUMBER (for Sime Darby employees only) T SHIRT SIZE:

_/ Category

EMAIL ADDRESS

M
Age

XL

Other
Start Time *Commitment Fee

Distance

Men Open Junior Men Open Senior Women Open Junior Women Open Senior WAIVER CLAUSE

18 - 40yrs 41 yrs & above 18 - 34yrs 35 yrs & above

10 KM 10 KM 10 KM 10 KM

7.30 am 7.30 am 7.30 am 7.30 am

RM 20.00 RM 20.00 RM 20.00 RM 20.00

Note : * All proceeds collected as commitment fee will be donated to charitable organisations.
In consideration of the Organizer accepting this entry and registration to participate in the above 10 KM Run, I hereby waive and release any and all rights or claims to damages I may have against the Organizer holding this Run, their agents representatives, successors, assigns, race sponsors for any and all injuries, death and invalidity I may sustain before, during or after the course of the event or arising as a result of it and I hereby indemnify the Organizers and keep them indemnified and waived against all claims or damages that arise in consequence of the above.

Singnature of Participant

Endorsement by S & R Council/

Secretary Residence Association

Date :

Date :

Details on Collection of Running Numbers and T-Shirts : 26 & 27 Apr 2012 from 2pm - 8pm at Bukit Jelutong Sales Gallery Office (Property Div)