EmailMeForm
Langebaan Lagoon Crossing 2012 Entry Form
Please complete one for each participant
Entry fee of 70 pp payable at registration on the day of event
Your Name
*
First
Last
Date of Birth
*
DD
/
MM
/
YYYY
E-mail Address
*
Cellphone Number
*
Hometown
*
Participation
*
Swimming
Rowing
SUP / Surfboard
Land Support
Other
Emergency Particulars
Emergency Contact Person Name
*
First
Last
Relationship
*
Cellphone Number
*
Do you suffer from any allergies or medical conditions?
(If YES, please elaborate...)
Other Questions
Please indicate whether you have done the Lagoon Crossing before:
*
2010
2011
Nope, this is my first time
Do you have a Wild Card?
*
Yes
No
Does your household sort domestic waste for recycling?
Yes
No
(Be honest...)