Phyllis Tuckwell Hospice, Farnham, Surrey

Surname/Family name:	................................................................................................
First name(s) in full:	................................................................................................
Address:	................................................................................................
Address (cont):	................................................................................................
	................................................................................................
Postcode:	......................................................
Date of birth:	(day/month/year) ......................................................
Telephone number:	......................................................
Please tick the boxes below that are relevant to you
Are you a female entrant:
Athletics Club (if applicable):	................................................................................................
Your e-mail (if applicable):	......................................................

Entry:	Fee, to include memento	tick
10Km (minimum age 15)	£9
10Km AAA Affiliated (minimum age 15)	£8
Fun Run - Juniors	£4
Fun Run - Mums Dads & Others	£4

I understand that the organisers and sponsors are under no liability whatsoever in respect of any personal loss or injury which may be sustained in the course of the event.

SIGNED: ..................................................................................... DATE: .............................

(Parental approval is required if under 16)

Under the terms of the Data Protection Act 1984, we are required to inform you that personal information is held on a computer for race management and distribution purposes only.