Nelson Mandela Remembrance Walk Registration Form:

1. Download: Mandela Remembrance Walk Registration Form,

2.  Complete

3.  E-mail to:        sacr.communications@gauteng.gov.za

Nelson Mandela Remembrance Walk Registration Form – 5km Walk

EMERGENCY INFORMATION COMPULSORY

PERSONAL INFORMATION

Surname:______________________________First Name:_________________________

Club:__________________________________Disability: Yes No Type of Disability:____________________

Province:_______________________________

Bate of Birth:____________________________

ID No:__________________________________Gender: M______F______

Please circle relevant category

Age on walk day:____________Category: (Open), (40 -49), (50 -59), (60-69), (70+)

Postal Address:

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

Contact No’s: Home/Work: (_____)___________________________________________

Cell No:_____________________Fax:__________________________________________

Email:____________________________________________________________________

Name of next of kin (in case of emergency)____________________________________

Relationship:__________________________

Contact numbers of next of kin on WALK DAY:_________________________________

Are you a member of a Medical Aid? Yes No

If yes, please indicate Medical Aid name:______________________________________

Medical Aid membership number:____________________________________________

Waiver

I warrant that all information supplied by me is true and correct and i, the below signed, intending to be legally bound, for myself, my heirs,

my executors and administrators, waive and release and any all rights and claims for damages i may have against the walk, and sponsors

and their representatives, successors and assigns for any and all injuries suffered by me in said event. I attest that i will participate in this

event as a walk, that i am physically fit and sufficiently trained for the completion of this event. Furthermore, I hereby grant full permission

to use my name and likeliness, as well as any photographs and any record of this event in which i may appear for any legitimate purpose,

including advertising and promotion.

Sign:___________________________

Date:__________________________

ENTRIES

To enter, registration forms can be collected, completed and dropped at Gauteng Department of Sport, Arts, Culture and Recreation, 35 Rissik Street, Johannesburg, ground floor reception area or can be

submitted on email at sacr.communications@gauteng.gov.za

Closing date for all entries is Monday, 08 December 2014

 

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