2021 GO-4-12 6 Hour Open

GO-4-12 6 Hour Open Entry Form

Saturday 17th April 2021
4 Person Team - for for all ages from 11 year old's to 99 year old's.
Team Name *
Category *

Male team Female team Mixed team (can be any ratio of male/female)
Team Captain *

First Name Last Name
Gender *
Birth Date

Day Month Year
Age on Race Day *
Phone Number *
Cell phone or home phone
Email *
example@example.com
Any Medical Conditions?
Please list conditions & treatments if applicable.
Emergency Contact Name *

First Name Last Name
Emergency Contact Email *
example@example.com
Emergency Contact Cell Phone *
Team Member 2 *

First Name Last Name
Gender *
Birth Date

Day Month Year
Age on Race Day *
Phone Number *
Email *
example@example.com
Any Medical Conditions?
Please list conditions & treatments if applicable.
Emergency Contact Name *

First Name Last Name
Emergency Contact Email *
example@example.com
Emergency Contact Cell Phone *
Team Member 3 *

First Name Last Name
Gender *
Birth Of Date

Day Month Year
Age on Race Day *
Phone Number *
Email *
example@example.com
Any Medical Conditions?
Please list conditions & treatments if applicable.
Emergency Contact Name *

First Name Last Name
Emergency Contact Email *
example@example.com
Emergency Contact Cell Phone *
Team Member 4 *

First Name Last Name
Gender *
Birth Of Date

Day Month Year
Age on Race Day *
Phone Number *
Email *
example@example.com
Any Medical Conditions?
Please list conditions & treatments if applicable.
Emergency Contact Name *

First Name Last Name
Emergency Contact Email *
example@example.com
Emergency Contact Cell Phone *

Support Crew Contact Details – supporting the team at the event
Support Crew

First Name Last Name
Email
example@example.com
Cell Phone Number
Additional support crew members for this team.
Please list Names, email, and cell phone numbers of additional support crew.
Entry Fees

Early Bird Entry Fee is until midnight 9th March 2021
GO-4-12 6 Hour Open team entry @ $320.00 Per Team *
4 team members
Additional Fees if required for team members and support crew ie if are staying at venue and are wanting a meal, this is not included in the team entry fee above.
Friday Night Meal @ $20.00 Per Person - Qty required:
Once your form is submitted an invoice will be sent from Ainsworth Ltd TA GO-4-12 for the above fees. Your entry is not confirmed until payment has been received.

Name, Email & Postal Address for invoice:
Name for Invoice *
Email for Invoice *
example@example.com
Address for Invoice *
Waiver *
Go to the GO-4-12 website for all Race Information www.go412.co.nz
Please verify that you are human *
Should be Empty:

GO-4-12 6 Hour Open Entry Form

Support Crew Contact Details – supporting the team at the event

Entry Fees