MOM MALLORCA OPEN MASTERS "MOM"

                                                                                         INDIVIDUELLES  ANMELDUNGS FORMULAR

Name ______________________________________________________________Lizenz nummer___________________
Adresse______________________________________________________________________________________________
Stadt________________________Land_________________________________PLZ________________________________
Geburts Datum_____________________Alters Klasse____________________MANNER- FRAUEN
Tel.__________________Fax________________________e-mail________________________________________________
Verein ___________________________________________Vereins Reg.Nummer__________________________________

(Start Zeiten fuer alle Läufe angeben) MAENER  -  FRAUEN  (mit X  ankreuzen was nicht zuttrif)

TOTAL INDIVIDUELLE STARTS_____  X 5 Euros = ______total

Zahlungs Art :       Bank überweissung  -  Barscheck

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

              ORT: ________________    DATUM:____________________  UNTERSCHRIFT:_______________________

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