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XV MOM. MALLORCA OPEN MASTERS. 18-19 April 2009
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_____________________________
| Saturday 18-04-2009 16.00 hours | Sunday 19-04-2009 9 hours | ||
| EVENT | TIME | EVENT | TIME |
| 400M FREE | 50M BACK | ||
| 50M FLY | 100M FLY | ||
| 100M BREAST | 50M BREAST | ||
| 50M FREE | 100M FREE | ||
| 100M BACK | 100M IND.MEDLEY | ||
(Indicate the entry times on each event) MEN - WOMEN (tick with X as non appropr
TOTAL INDIVIDUALES EVENTS_____ X 4 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
XV MOM. MALLORCA OPEN MASTERS
PLACE: ________________ DATE:____________________ SIGNATURE:_______________________
Please, print de file, fill it and send it per fax to the Balearic Swim Federation +971-764630