Welcome to the Rory Lowther Memorial Challenge 2012 Web Registration Form

NB: Do NOT use the browser back, forward or refresh controls.
Once your registration is complete, you will be able to print out or save your registration in PDF format.
Please note that you must have the free Adobe Reader  installed to do this.

This form is for ready-to-go teams and individuals who don't have a team yet.

Team Name:*    (if you don't have a name, use anything, you can change it later)
(Please do not use names that may be offensive to others)
School Name:  (Only enter this if you are part of a school team)
Category: -Select- Seniors High School Junior Primary School Men Open Women Open Mixed Open High School Senior U19 Male U19 Female U17 Male U17 Female U15 Male U15 Female U13 Male U13 Female
Payment: -Select- EFT Bank Deposit

Challenger A
First Name:*
Last Name:*
Gender: -Select- Male Female
Date of Birth:* (yyyy/mm/dd)  (please use 4-digit year, yyyy/mm/dd)
T-Shirt Size: -Select- Small Medium Large X-Large
Cell:*  (please use dashes, ###-###-####)
Phone:  (please use dashes, ###-###-####)
Email:

	Postal
Address:
City:
Code:

Emergency Contact Person:
Full Name:*
Cell:*  (please use dashes, ###-###-####)
Phone:  (please use dashes, ###-###-####)

Please list any allergies or medical conditions:


Medical Aid:
Medical Aid:
Member No.:
Phone:  (please use dashes, ###-###-####)

Challenger B
First Name:*
Last Name:*
Gender: -Select- Male Female
Date of Birth:* (yyyy/mm/dd)  (please use 4-digit year, yyyy/mm/dd)
T-Shirt Size: -Select- Small Medium Large X-Large
Cell:*  (please use dashes, ###-###-####)
Phone:  (please use dashes, ###-###-####)
Email:

	Postal
Address:
City:
Code:

Emergency Contact Person:
Full Name:*
Cell:*  (please use dashes, ###-###-####)
Phone:  (please use dashes, ###-###-####)

Please list any allergies or medical conditions:


Medical Aid:
Medical Aid:
Member No.:
Phone:  (please use dashes, ###-###-####)

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