* SURNAME:

* ADDRESS:

* FIRSTNAME:

* D.0.B:

* AGE @ 19/6/06

* GENDER:

MALE FEMALE

* POSTCODE:

* RUNNING CLUB:
(if attached)

* TELEPHONE:

Pre-Entry Fee £6 in advance, (£8 on the day)

*I am now posting cheque/ PO for £ made out to Mersea Island Lions Club, plus 9" x 6" SAE (see below)

* To Mersea Island Lions Club: I am medically fit to run and accept that the organising club and its members will not be held liable for any loss, accident or injury, before, during or resulting from the event. The organisers reserve the right to cancel the event without notice if necessary. Please tick box

Minimum age for entry is 17 years

N.B: Please send fee and 9" x 6" SAE to Mr Terry Walker, 26 Garden Farm, West Mersea, CO5 8ES. Entry form also, if not entering "online"