Form | Ultra Series SA

First Name *

Surname *

Address *

Suburb *

State *

Country *

Postcode *

Gender *

Female

Male

Date of Birth *

Email *

Mobile Phone *

Are you an AURA member? *

No

Yes

Are you a current USWA member? *

No

Yes

What is your country of citizenship? *

Number of Mobile Phone you are carrying during event *

Do you understand the mandatory items that are required to compete on event day. Do you acknowledge that if you do not have these items at the start line you will not be able to run the event, and the RD will not assist with this? *

No

Yes

Have you read the race rules and manual? *

No

Yes

Have you trained appropriately for the event you are entering? *

No

Yes

Do you understand that all events are on open courses and may be utilised by other people and you are to be courteous and ethical in all manners? *

No

Yes

Do you understand that you are responsible for your own medical insurance? Event insurance does not cover individual competitors medical insurance. *

No

Yes

Do you have any current medical issues the event organisers should be aware of? *

No

Yes

Please outline medical issues the event organisers should be aware of

If you are taking medications the event organisers should be aware of please list them

Do you have any allergies? *

No

Yes

Name of next of kin *

Address of next of kin *

Phone # for next of kin *

Do you have Private Health Insurance? *

No

Yes

If You Have Private Health Insurance, who is it with?

Select the Lighthorse event you wish to enter *

Do you accept the waiver and disclaimer? *

No

Yes

1. I acknowledge that this event involves competing on roads and tracks, all of which may be utilized by others. I acknowledge that there are dangers involved in this event included (but not limited to): the condition of participant’s equipment; road and traffic conditions; inclement weather; hypothermia; heat exhaustion; actions of participants and non participants. I accept the risks associated with the event. 2. I certify that I have not been advised not to compete in this event by a qualified medical person and that I have undertaken sufficient training to do so. 3. I consent to receive medical attention during the event where deemed necessary due to injury, illness or accident. 4. I bind myself, my executors, administrators, heirs, successors and assigns as follows: a. I discharge and release the event organising committee, event organisers, Ultra Series WA, Ultra Series Australia, Australian Ultra Runners Association Inc, sponsors, volunteers, community organisations, State, Federal and Local authorities,in which the event is held and their representatives from all liability for death, disability, personal injury, damage to property, theft and all foreseeable risks, claims or actions of any kind, however caused, resulting from my participation – directly or indirectly – in this event. b. I further indemnify and hold harmless all entities and persons mentioned in paragraph 4 (a) from all liabilities, claims or actions as mentioned above. 5. I consent to the use of my image for any legitimate purpose by the event organisers and or event sponsors, in the case I am photographed or filmed during the event or related activities. 6. I have read the Race Manual and Rules document for this event and agree to abide by them. 7. I understand that no pacers are allowed to accompany me at any time during this event. 8. I will be respectful and silent when moving in the vicinity of the dawn service and last post.

ENTRY FORM