e-mail Address Telephone Number

First Name Last Name Entries 1 Distance / Event 15km ASA Licence ASA Club Member? YesNo A temporary license will be included with the entry. Athletic Club Name Age Category 14-19 Open 40-49 50-59 60-69 70+ Gender Female Male Subtotal   Please complete all of the required information first before adding another. Add Another

First Name Last Name Entries 1 Distance / Event 15km ASA Licence ASA Club Member? YesNo A temporary license will be included with the entry. Athletic Club Name Age Category 14-19 Open 40-49 50-59 60-69 70+ Gender Female Male Subtotal   Please complete all of the required information first before adding another. Add Another

First Name Last Name Entries 1 Distance / Event 15km ASA Licence ASA Club Member? YesNo A temporary license will be included with the entry. Athletic Club Name Age Category 14-19 Open 40-49 50-59 60-69 70+ Gender Female Male Subtotal   Please complete all of the required information first before adding another. Add Another

First Name Last Name Entries 1 Distance / Event 15km ASA Licence ASA Club Member? YesNo A temporary license will be included with the entry. Athletic Club Name Age Category 14-19 Open 40-49 50-59 60-69 70+ Gender Female Male Subtotal   Please complete all of the required information first before adding another. Add Another

First Name Last Name Entries 1 Distance / Event 15km ASA Licence ASA Club Member? YesNo A temporary license will be included with the entry. Athletic Club Name Age Category 14-19 Open 40-49 50-59 60-69 70+ Gender Female Male Subtotal   Please complete all of the required information first before adding another. Add Another

If you buy multiple race entries you must also
collect them all in a single batch.

Donation (Optional)	Please consider making a donation to the Woodside Special Care Centre. R
Payment	I have read the terms and conditions.

For enquiries about online entries contact entries@pinelandsathleticclub.co.za.