Site Race Entry Form(£2 entry fee / free for Running Section Members)
Personal Details
Surname: / Forename:
Date of Birth: / Age: / Sex: Male / Female
Work’s Address: / Contact Telephone:
Email:
Team Name(where appropriate)
Health Screening (please circle as appropriate)
  1. Has a Doctor or Medical Professional ever said you have a heart condition?
/ Yes / No
  1. Do you have a family history of heart disease, stroke or diabetes?
/ Yes / No
  1. Do you feel pain in your chest when you do physical activity?
/ Yes / No
  1. Have you ever had high blood pressure, high cholesterol or cardiovascular disease?
/ Yes / No
  1. Do you suffer from Asthma / Breathlessness / Wheezing?
/ Yes / No
  1. Are you Diabetic (Type 1 or Type 2)
/ Yes / No
  1. Do you ever suffer from dizziness, vertigo, balance problems or loss of consciousness?
/ Yes / No
  1. Are you pregnant or have you given birth in the last 12 months?
/ Yes / No
  1. Are you aged over 65 and unaccustomed to regular exercise?
/ Yes / No
  1. Do you currently have any muscles or joint pain / injuries?
/ Yes / No
Please use this space to provide any additional information relating to the questions above:
Please read the terms and conditions and the declaration carefully before signing below.
Terms & Conditions
  1. Previous or existing medical conditions must be disclosed prior to the event. It is the discretion of the event organisers to prevent participation if entrants are deemed ‘at risk’.
  2. Any disruptive behaviour or conduct deemed ‘unsporting’ will lead to offenders being excluded from the event.
  3. Participants should only compete at a level that is in tandem with their ability and fitness level and must consider their own safety and the safety of others at all times.
  4. All entrants must be over the age of 16 with parental consent required for participants under the age of 18.
  5. Any injuries that occur during the event must be reported to an event organiser or steward immediately.
  6. All participants give their consent to being photographed with images being used for our website.
Declaration
Participants are reminded that ClubAZ cannot be held responsible for any injury incurred during or after participation in the event and thoroughly recommend that all participants consult their doctor to ensure they are fit to participate. In signing this document, I assume all risks and responsibility for any harm, loss, damage, property damage, personal injury or death to me or others resulting from, arising out of, or anyway in relation to my partaking in this event. I have also read and understood the Risk Assessment and Safety Advice.
What next?
  • Please return you completed application form and £2 entry fee to reception at Hulley’s or Mulberry’s by Friday1 December. Your race number will be ready for collection on the day of the event.

All information in this document will be treated in confidence and will only be assessed by a qualified fitness professional.

Please note that if there are any concerns as to your health status you may be required to obtain medical clearance before

partaking in the event. Upon signing this form, I agree that all the information I have provided above is correct to the best of

my knowledge, I agree to the terms and conditions and understand that as per the declaration above I am entering this event

at my own risk.

Signature: / Date: