Long Course Championships Registration Form

Masters Swimming NT 2022 Long Course Championships Registration Form
Location: Parap Swimming Pool and Alice Springs

Race Dates: Saturday 17 September 2022 and Sunday 18 September 2022

Time: 3 pm (Sat) and 8 am (Sun)
Participant Information
Full Name

First NameLast Name
Age
As at 31/12/2022
Date of Birth

MonthDayYear
Date
Gender
Phone Number

Area CodePhone Number
Email
example@example.com
Club Name

Street Address Line 2

CityState / Province

Postal / Zip Code
MSA Registration Number
Should be 6 digits
Emergency Contact Person

First NameLast Name
Emergency Person Phone Number

Area CodePhone Number
Relationship to Emergency Contact Person
Event Registration

*Entries are limited to five per person, with not more than four on one day.

Events on Saturday 3pm

Events on Sunday 8am

	Select Events*	Entry Time
100m Butterfly
200m Backstroke
100m Freestyle
200m Breaststroke
50m Butterfly
100m Backstroke
1500m Freestyle (Qualifying times, no form strokes)

Terms/ Waiver/ Release
I will follow the rule and regulations of the race event.I am in good shape, health, and condition.I don't have any medical condition or medical history that will be affected if I participate in this event.I acknowledge that this race requires physical activity and there are possible risks and danger.I release the race event organizers for any responsibility in case of an accident, illness, or injury.I allow taking my photos or the procedure images that can be used for the event portfolio or advertising.I confirm that all information in this registration form is accurate and true.
Participant's Signature

Clear
Date Signed

MonthDayYear
Date
Should be Empty: