Kampala Marathon

MTN

2012

Self Help Africa - The Kampala Marathon 2012 Registration Form

To register, please return your completed form (including signed terms & conditions), registration fee, and a photocopy of your passport to:

Self Help Africa, 3rd Floor, Fitzroy House,18-22 Ashwin Street, London, E8 3DL
Please use BLOCK CAPITALS to fill in this form. Details should match the information on your passport.

Personal Details
Title: ________________________________ Forename: ____________________________ Surname: _____________________________________ Preferred Name: _______________________________

Address: __________________________________________________________________________ __________________________________________________________________________________ Tel (work): ____________________________ Tel(home): ____________________________________ Mobile: ______________________________ Email: _______________________________________

Passport Details
Passport Number: ______________________________________________________________________ Date and Place of Issue: __________________________________________________________________ Date of Birth: _________________________ Nationality: ___________________________ Place of Birth:____________________________________ Expiry Date: _____________________________________

Next of Kin
Name: _______________________________ Relationship: _______________________________________ Email: ____________________________________

Tel (in case of emergency):_________________________

Additional Information
Can we share your contact details with other run participants? Do you want to join the Self Help Africa mailing list? Accommodation: Option A) Shared Twin Room Option B) single occupancy (additional fee: 300) YES YES NO NO

Registration Fee & Passport

I enclose the registration fee of 250 (fill in payment details on page 2) I have enclosed a photocopy of my passport YES YES

Important Note: Passports must be valid for at least three months after your date of return, and must have three full pages free.

Terms & Conditions

1. 2. The registration fee of 250 (non-refundable) and a clear photocopy of your passport should be attached to this registration form. You will undertake to raise the minimum specified funds for The Kampala Marathon (2,500). Cheques and postal orders should be made payable to Self Help Africa, or payments can be made by phone (Visa/ MasterCard/ Laser). The balance to be paid by the 1st of October. The participant must be 18 years of age before the departure date of the event, or be accompanied by a parent or guardian. We reserve the right to alter the itinerary for operational or security reasons. Participants are responsible for their own vaccinations. Please consult your doctor about your requirements. Your passport must be valid for 3 months from the date of your return and must have 3 full blank pages free. You are responsible for obtaining your own visa for travel into Uganda. Information and application forms can be downloaded from http://www.ugandahighcommission.co.uk/ConsularInformation/VisaInfo.aspx and must be submitted either in person or by mail. Please note that Irish nationals are not required to pay for a visa. The Self Help Africa Challenge includes both participation in the Kampala road race and ancillary other activities organised by Self Help Africa in Uganda. Participants on the Self Help Africa Uganda Challenge take part at their own risk and hereby indemnify Self Help Africa and its agents against claims arising from their participation in the Challenge for loss, damage or injury howsoever arising. This includes any loss, damage or injury caused to participants during the Kampala road race arising out of the actions or negligence of the race organisers. All participants in the Challenge must obtain a policy of travel insurance to cover their participation in this event. Self Help Africa will not insure participants. All participants will supply a copy of their travel insurance to Self Help Africa at least four weeks in advance of the event - Self Help Africa reserves the right to refuse entries to the Challenge if proof of adequate insurance is not furnished.

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10. If you are refused passage and/or entry/exit to or from Uganda, any additional costs incurred are your responsibility. 11. If you have any medical conditions that could be affected by strenuous activity, or you are over 65, you must provide to Self Help Africa in advance of participation a written statement from your doctor advising that you are cleared by him/her for participation. By completing this application form, you are confirming that you are in good health and are fit to partake in the Uganda Challenge.You accept that all instructions given to you by SHA representatives on the challenge must be observed for your own safety. 12. There will be no refund on any monies raised, if you withdraw from the trip. 13. All flights and travel arrangements are subject to change.You will be notified of any changes with the soonest possible notice. 14. Transfers to/from London airport are at your own expense. 15. If you decide to stay on in Uganda, after the organised itinerary, you are responsible for your own return travel arrangements. 16. Self Help Africa reserves the right to cancel the event if an advisory is issued against travel or for other operational or security reasons.

Declaration:

I am registering to take part in the Kampala Marathon, Half Marathon or 10km (November 2012) I agree to abide by the above terms and conditions. I accept responsibility for my actions and safety whilst in Uganda. I also confirm that to the best of my knowledge, my health and fitness is sufficient to allow me to take part in this event. Signed: ___________________________________ Name (print): ________________________________ Date: _______________________________________

Deposit - Payment details Option A) I enclose a cheque / postal order for 250 (payable to Self Help Africa) Option B) I have made a payment of 250 by credit/debit card by phone to Self Help Africa Call: 01743 277 170 and speak to Jo or Rachel to make a payment by phone (Visa/ MasterCard/ Laser)