Derby Fun Run 3km walk, jog, run Sunday 17th April 2016 10:30 Parent name: ………………………………… Child Class:……… Email address : …………………………………………………………… Mobile number: …………………………….(emergency contact on the day) 3km walk, jog, run Sunday 17th April 2016 10:30 Pride Park Entry 1: Full name: ……………………………………… Gender: M / F DoB: …………………… Medical condition: ………………………. Entry 2: Full name: ……………………………………… Gender: M / F DoB: …………………… Medical condition: ………………………. This friendly event is open to all: children, teachers, staff, their friends and family, pushchairs, wheelchairs, walkers, 1st time runners, PB chasers… Entry 3: Full name: ……………………………………… Gender: M / F DoB: …………………… Medical condition: ………………………. Entry 4: FREE! Full name: ……………………………………… Gender: M / F DoB: …………………… Medical condition: ………………………. ALL WELCOME! 4 good reasons to join: Get fit for spring! Raise money for school and Cancer Research Medal to all finishers. Finishing lap around the iPro stadium. Add extra applicants on reverse Cost: £5 per runner (4th entry free) I am medically fit to take part and I enter at my own risk. I will not hold responsible the organisers or any person involved in the event for any injury/illness or for any property lost, stolen or damaged. I give my permission for free use of my name, voice or picture in any broadcast, telecast, advertising promotion or other account of this event. If I am under 18, my parent/guardian has agreed for me to participate. If I am under the age of 9, I must be accompanied by a responsible adult. Please return your entry form with payment to school by 21st March or email us: funrunderby@gmail.com £……. enclosed Signature: …………………………………