SUNDAY 26 July 2015 - Pomona King of the Mountain Festival

BENDIGO BANK INTERNATIONAL
MOUNTAIN CHALLENGE RACE ENTRY FORM SUNDAY 26 July 2015
SURNAME ADDRESS GIVEN NAME POSTCODE E
GENDER
MALE/FEMALE
OCCUPATION PHONE
EMAIL
DATE OF
BIRTH
NATIONALITY Brief history of applicant’s background or running career:
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------CATEGORY: (Please tick)
A – Men’s Open (21-39)
C – Veteran Men (40-49)
B – Women’s Open (21-39)
D – Veteran Women (40+)
F – Junior Men (13-20)
G – Junior Women (13-20) E – Masters Men (50+)
T-SHIRT SIZE: (Please tick one only)
Small
Medium Large
Ex-Large DECLARATION FOR ALL ENTRANTS:
I,
declare that I have
no medical or physical condition that would affect the safety or well being of myself, other
competitors or the race itself.
SIGNATURE OF ENTRANT:
PARENT/GUARDIAN (if under 18):
DATE: ______________________
Pomona King of the Mountain Festival
All correspondence to the Chairperson: Heather Manders
Phone: 041 111 4077
Email: [email protected]
Web: www.kingofthemountain.com.au
PO Box 144, Pomona Q 4568
ABN: 61 300 961 161
WAIVER RELEASE AND INDEMNITY
1. In consideration of the acceptance of my entry in the King of the Mountain Race, I hereby agree
to comply with all of the rules and regulations and instructions of the King of the Mountain Festival
and Race and it’s organizers.
2. For myself, my executors, administrators, heirs, next of kin, successor and assigns, I hereby:a. Waive and release any and all claims that I may have against the Events Committee, their
officers, directors, members, volunteers, employees, agents, sponsors, The State of
Queensland, Sunshine Coast Regional Council, or any one or more of them, their
executors, administrators, heirs, next of Kin, successors or assigns (“the releasees”)
including any and all claims for damage caused by the negligence of any of them arising
out of my participation in the event and its related activities, together with any costs
including attorney’s fees that may be incurred as a result of any such claim either valid or
not, and
b. Indemnify and hold harmless the releasees and each of them against any such claim that I
or my guests or any one or more of my executors, administrators, heirs, next of kin,
successors and assigns may have or assert and against any costs including attorney’s
fees with respect thereto.
3. I hereby acknowledge that I have sole responsibility for my personal possessions and athletic
equipment during the King of the Mountain Race event and its related activities.
4. I hereby acknowledge that participation in the King of the Mountain Race competition carries with it
a potential hazard. I therefore release the King of the Mountain, its Event Committee, their officers,
directors, members, volunteers, employees, sponsors, of any liability resulting from injury or death
during the event and its related activities.
5. I hereby attest and verify that I am physically fit and have sufficiently trained for this competition
and that a licensed medical doctor has verified my physical condition. Entrants can enter one
category only.
6. Medical and/or physical condition –
a. Any special medical or physical condition must be declared and attached to the entry form.
b. In addition, any competitors with special medical or physical condition must contact the
Race Coordinator one (1) week before the Race, on the phone number listed below.
7. I hereby consent to receive medical treatment, which may be deemed advisable in the event
of injury, accident or illness during the King of the Mountain event.
8. I hereby permit the free use of my name and picture in broadcasts, telecasts and the press as
they pertain to the event.
9. I understand that my entry is non-transferable and in the event that I am unable to compete in
the King of the Mountain race a refund will not be issued.
10. I understand that if conditions beyond the control of the King of the Mountain Race Directors
the course could change in any shape or form with or without further notice.
RACE RULES AND REGULATIONS
1. In the interest of individual runner well being all medical or physical conditions must be declared at
the time of submission of the Entry Form.
2. All entrants must sign the declaration before starting.
3. All official directions must be obeyed at all times and entrants must follow the designated course.
4. Entrants DESCENDING the mountain have the right-of-way. Failure to obey this rule
means instant disqualification.
5. All safety precautions are to be taken by each entrant, so as not to cause injury to oneself or
to other entrants.
6. Entrants can enter one (1) division only.
7. Protests must be lodged with the official judges no later than five (5) minutes after the race
has been declared finished.
8. The Judges decision is final and no correspondence will be entered into.
9. The Organisers reserve the right to reject or cancel any entry at any time. The completion of the
Entry Form does not guarantee acceptance into the Race.
10. Number of actual competitors in the race is limited to a maximum of one hundred (100) runners.
11. A late fee of $20 will be charged for all entries received after the closing date (if competitor number
limit allows acceptance of entry).
12. Competitors who have nominated and been accepted, and have to withdraw from the race will
receive a
$40 refund, providing they notify the race director (Barry Stewart) before the closing date. A medical
certificate may be required to claim the refund. There will be no refund of the entry fee if the notification
of withdrawal is received after the closing date.
Pomona King of the Mountain Festival
All correspondence to the Chairperson: Heather Manders
Phone: 041 111 4077
Email: [email protected]
Web: www.kingofthemountain.com.au
PO Box 144, Pomona Q 4568
ABN: 61 300 961 161
13. Competitors who have their nomination accepted will be notified as soon as possible.
14. Any nomination not accepted will have the fee refunded or cheque returned.
15. Race numbers must be displayed on the front and back of each competitor. Race numbers
must not be obscured or modified in any way or the entrant will be disqualified.
16. Bottled water will be provided at the finish for all entrants
17. Entrants must be 13 year of age or older
18. Any organization may sponsor an entrant and if successful the organization will receive the
prize money and the entrant will receive the prize, trophy and medallion.
19. ALL ENTRANTS MUST REPORT TO THE RACE CO-ORDINATION AREA BY 1.45PM TO
COLLECT THEIR RACE NUMBERS AND RACE BRIEFING.
DECLARATION FOR ALL ENTRANTS:
I,
declare that I
have read and agree to the Waiver and Indemnity, and the Race Rules and
Regulations
SIGNATURE OF ENTRANT
PARENT/GUARDIAN (If under 18)
Date:
Declaration by runners with amateur status.
I hereby declare that any prize money made available to me for this event will be handed
over in full to
club.
SIGNATURE OF RUNNER
ENTRY FEE: $100
Payment Options:
Cheque/money order payable to:
Direct Deposit:
Cooroy Pomona Lions Club
Bendigo Bank BSB 633108 A/C 1425 24503
Applications Open
May 14th, 2015
Applications Close
July 16th, 2015
CLOSING DATE: Entries close on receipt of 100 entries
APPLICATION FORM Please print carefully, complete and sign. Post with
cheque, money order or proof of direct deposit to:
King of the Mountain – Race Nomination
PO Box 144
POMONA QLD 4568
Enquiries to Race Co-ordinator, Barry Stewart on 07 5485 1030
Pomona King of the Mountain Festival
All correspondence to the Chairperson: Heather Manders
Phone: 041 111 4077
Email: [email protected]
Web: www.kingofthemountain.com.au
PO Box 144, Pomona Q 4568
ABN: 61 300 961 161