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: PAYMENT OPTIONS Cheque: Make cheques payable to Tough Guy & Gal Direct Debit: Please pay electronic transfer into ASB Taupo 12-3162-0075818-61 Event Promotions. You must attach evidence of payment receipt to your entry and state name for reference when depositing. WAIVER & RELEASE STATEMENT In consideration of the acceptance of my entry for the event, I hereby waive, release and discharge Event Promotions Limited, its director/s and staff, owners and/or custodians of land and property on and over which the event is being conducted, event sponsors and promoters, suppliers of product and services (including medical services), volunteers and volunteer groups, and all other persons, entities or groups associated with the planning and conduct of the event (individually or collectively referred to as the “indemnified parties”), from any liability and claims that arise from losses, injuries and or damage however caused (whether fatal or otherwise) that I may suffer from my preparation for and/or participation in this event. Further, I hereby indemnify and hold harmless the above described “indemnified parties” from all actions, suits, proceedings, claims, demands, losses, damages, penalties, fines and other financial impositions however arising. This waiver, release, discharge and indemnity is provided for me, my executors, administrators and assigns. I agree to comply with the rules of the event and will compete entirely at my own risk. I authorise the use of my name, voice, picture and any information provided by me on this entry form, and without payment, for the purpose of any broadcast, telecast, communication, promotion, advertising or activities associated with the current or future events or other events promoted by or on behalf of Event Promotions Limited. I acknowledge that if the event is cancelled due to acts of nature, my entry fee will not be refunded. I confirm, where this entry is completed on behalf of me and/or others, that these others have been made aware of the above statement and that each of them confirm the waiver, release, discharge and indemnity set out therein, including on behalf of their executors, administrators and assigns. Refund Policy. No refunds will be given within 7 days of each event - no exceptions. A $10.00 administration fee will apply prior to this date. Signed: Date: All competitors must sign their Waiver & Release Statement Signature of entrant (or guardian if under 18 years) Online entry available - www.eventpromotions.co.nz Event No: (official use only) EVENT MERCHANDISE Women’s T-shirt S M L XL XXL $35.00 Men’s T-shirt S M L XL XXL $35.00 Unisex Hoodie XS S M L XL XXL $60.00 GST No. 62-658-398 POST ENTRY Please post entry, cheque and / or evidence of payment receipt to: Tough Guy & Gal, PO Box 324, Rotorua 3040. EMAIL ENTRY Email entry form/s and proof of payment to us at: [email protected] Wellington Fees Fee for months of February - 1st May $65.00 Fee from 2nd May until 14th May $70.00 Fee from 15th May $80.00 Hawke’s Bay Fees Fee for months of February - 1st May $65.00 Fee from 2nd May until 16th July $70.00 Fee from 17th July $80.00 Hamilton Fees Fee for months of February - 1st May $65.00 Fee from 2nd May until 28th May $70.00 Fee from 29th May $80.00 Palmerston North Fees Fee for months of February - 1st May $65.00 Fee from 2nd May until 23rd July $70.00 Fee from 24th July $80.00 Bulk Entry Discount - All bulk entries MUST be received at least three weeks prior to each event to qualify for the discount, minimum 20 people. EVENT FEES Please tick one MULTI-EVENT FEES Please tick one BULK ENTRY FEES Please tick Beanie $20.00 Sports Cap $20.00 Sweat Band $10.00 Sports Bag $40.00 Pilsner Stemmed Glass $15.00 Drink Bottle $10.00 Cure Kids Donation Enter amount Entry Total $ COMPETITOR DETAILS Images of all products available at: www.eventpromotions.co.nz VENUE/DATE: TOUGH GUY AND GAL *Palmerston Nth Saturday 4th August * Indicates Corporate or Gym/Club Team Option available *Wellington Saturday 26th May Hamilton Saturday 9th June Auckland Saturday 30th June *Auckland Sunday 1st July *Hamilton Sunday 10th June *Hawke’s Bay Sunday 29th July *Rotorua Saturday 18th August 12km Course 6km Course COURSE OPTION Please tick one tough guy and gal challenge Fundraising: I want to know more about fundraising for Cure Kids. (Please Tick) Auckland Fees Fee for months of February - 1st May $65.00 Fee from 2nd May until 19th June $70.00 Fee from 20th June $80.00 Rotorua Fees Fee for months of February - 1st May $65.00 Fee from 2nd May until 6th August $70.00 Fee from 7th August $80.00 60.00pp Corporate or Gym/Club Team - All teams must have a minimum of five team members all competing in the 6km event, there is no maximum number of team members. Standard or bulk entry fees apply. See www.eventpromotions.co.nz for terms & conditions CURE KIDS FUNDRAISING doing our bit for cure kids Multi-Event Entry from 20th June Enter two events $130.00 Enter three events $175.00 Enter four events $215.00 Enter five events $250.00 Ultimate Tough Guy and Gal Challenge - All 6 venues! (Free hoodie & T-shirt) $280.00 Multi-Event Entry until 19th June Enter two events $110.00 Enter three events $155.00 Enter four events $195.00 Enter five events $230.00 Ultimate Tough Guy and Gal Challenge - All 6 venues! (Free hoodie & T-shirt) $260.00 First Name: Last Name: Gender: Male: Female: Date of Birth: DOB must be completed for grade placement Email: for E-ticket confirmation Postal Address: Telephone (Day): Emergency Contact: Corporate or Gym/Club Team: Mobile: Emergency Ph: MEDICAL INFORMATION Do you have any existing medical conditions that we need to know about in case you/they need medical treatment? Eg. Heart condition, Diabetes, Allergies etc. Yes No If you answered yes, please list any relevant medical conditions: (if applicable)
