Grand Prix Entry Form – Centurion RC

Form Notes

Name *

First

Last

Address *

Post Code *

Date of Birth *

Male/Female *

Male
Female

Email *

Mobile Number *

Affiliated Club *

Club Name

URN (Unique Runner Number) *

URN if known

Enter 5 Mile Event *

January
February
March
April

Full Series - £40 Affiliated (£50 U/A) ~ Individual Race - £8 Affiliated (£10 U/A) ~ Extra £1 for on the day entries.

Select Race Entry for MMAC Handicap in February *

I am V35 and wish to be entered into the Handicap race
I don't wish to enter

Race time for 5m for handicap prediction

Select your Membership Payment *

BACS* (Sortcode: 40-16-25; Account: 11106643)

* Our preferred payment method is via bank transfer. Please enter GP and your name as the payment reference & keep a receipt.

I declare that I am an amateur as defined by UK Athletics and will abide by their rules. I confirm that I am medically fit and will run entirely at my own risk. I understand that the race organisers will not accept any responsibility for any injury, loss or damage as a result of my participation in this event. Data Protection: You agree that we may publish your Personal Information as part of the results of the Event and may pass such information to the governing body or any affiliated organisation for the purpose of insurance, licenses or for publishing results either for the event alone or combined with or compared to other events. Results may include (but not be limited to) name, any club affiliation, race time and age category.Preferred method of contact for future series, results, prizes (please tick, by ticking you agree for us to contact you in this way):

Email
Phone
Post
None