Registration Form

 
 

     The Nevis HIV /AIDS Coordinating Unit  

 

        

 
 

 

 

 

 

 

 

 

 

 

                                                

Office Use Only

Initials

Reg. Fee Received

 

 

Run /Walk

 

 

Finishing Position

 

 

Adult (A)

Child (C)

 

 

                                                                                

 

 

Registration Form                                     

 

 

Date: November 28th 2009        

From: Cotton Ground Round About to Memorial Square

Starting time: 4:00pm

 

 

 

Name ……………………………………………………………………......................................................................

 

 

Address…………………………………………………………………………………………………………………..

 

 

DOB: ………………………………………… Age………  Male: ……………… Female: ………………………..

 

 

Email…………………………………………………………………………………………………………………….

 

 

Daytime telephone#................................................................. Mobile#………………………………………………..

 

 

·         An Entry form must be completed  for the run/walk

·         Entry fee is $35:00 for adults/$25:00 for  Children (12 and Under)

·         We at the HIV Unit request that you get advice from a doctor before embarking on a long distance run or walk.

·         For entrants under eighteen, this form must be signed by a parent/guardian

 

 

I declare that I am  participating at my own risk and I understand  that I cannot  hold the event organizer or HIV/AIDS Unit responsible for any injuries sustained by myself or others.

 

 

   Signed…………………………………………..                                                          Date: …………………….................

 

 

Thank You for your contribution. Together we can stop Stigma and Discrimination and the spread of HIV/AIDS in our Community

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