KNOWLE & DORRIDGE RUNNING CLUB
ZERO TO 3 MILES CHALLENGE JAN 15 - APPLICATION FORM
Surname
DOB
/
/
(Sorry but O18s only)
Forename(s)
Home address
Postcode
Tel (H)
(W)
(M)
Email address
Contact in emergency (optional)
Any relevant medical conditions or other factors that we should be aware of for your safety and welfare?
By signing below I apply to participate in the Knowle & Dorridge Running Club from Zero to 3 Miles Challenge and
declare that the information given above is correct. I agree to do my best to follow the training plan and abide by the
guidance and recommendations of the club’s management and leaders. I understand and agree that 1) my
participation in the challenge is entirely at my own risk and that I will consult with my GP if necessary and must
undertake personal care and responsibility for my own health and fitness and for any of my property and 2) the club
and or its management and or its leaders will not be legally responsible for any proven injury, loss and or damage
sustained by me to my person or to any property, however caused, even if by negligence – except that liability will
be accepted only for personal injury to me in circumstances where it can be established in law that the club or its
management or its leaders have been negligent.
The club will use its best endeavours to fulfil the Challenge as provided for in the training plan but is unable to accept
any responsibility for factors outside its control such as, for example, illness or adverse traffic or weather conditions.
I will pay the course fee of £20 at the outset of the challenge and understand that this is non – refundable except in
the absolute discretion of the club’s management. The preferred method of payment please is by electronic bank
transfer to our account sort code 30-97-78 account no; 3043 7968 quoting your name and CHALLENGE as the
reference. Cheques payable to Knowle and Dorridge Running Club.
Please submit this form to the course leader Geoff Lewis via - geoffrey.lewis@blueyonder.co.uk
Thank you.
Signature
Date