MOM MALLORCA OPEN MASTERS "MOM"

                                                                                                  INDIVIDUAL ENTRY FORM

Name______________________________________________________Licence number___________________________
Adress_______________________________________________________________________________________________
City___________________________Country____________________________Zip Code_____________________________
Date of Birth____________________Age group__________________________MEN- WOMEN
Tel.__________________Fax______________________e-mail__________________________________________________
Club _____________________________________________________Club Reg.Number_____________________________

(Indicate the entry times on each event)    MEN  -  WOMEN  (tick with  X  as non appropr

TOTAL INDIVIDUALES EVENTS_____  X 5 Euros = ______total       

 Payment details:       Bank transfer    -    Check 

RELEASE FROM LIABILITY

I, the undersigned participant,hereby certify that I am physically fit and have not ben otherwise informed by a medical 
practitioner. I acknowledge that I aware of the risks inherent on Masters swimming ( training and competition) including 
posible permanent disability or death, and agree to asume all risks.

I hereby waive all rights to claims against the organizers, for loss and damages araising out of my participation at the 
MOM. MALLORCA OPEN MASTERS

                    PLACE: ________________      DATE:____________________        SIGNATURE:_______________________

Please, print de file, fill it and send it per E-mail to the
Balearic Swim Federation fbn@fbnatacion.org  ò   JordiI Granados granados.j@telefonica.net