BASE RUN CLUB

1
Your Name* This field is required.
First Name
Last Name
2
Phone Number* This field is required.
Area Code
Phone Number
3
Email* This field is required.
example@example.com
4
Emergency Contact Details* This field is required.
Emergency Contact Full Name
Emergency Contact Number
Please Select
Please Select
Yes
No
Do you have any medical conditions we should be aware of?
5
Details of medical condition:
6
Running Experience* This field is required.
Casual Runner (1-3 x per week)
New to running
Experienced runner
7
What made you want to join our Run Club?* This field is required.
Find a community of like minded people
Get into running/build consistency
Train for an event or goal
8
How did you hear about the run club?* This field is required.
Please Select
Please Select
Instagram
Base Physio Clinic
Local Flyer
Through Base Gym
Friend
9
Base Physio + Performance RUN CLUB (Base Run Club) ACTIVITY WAIVER

By accepting, and attending the Base Run Club you hereby covenant and agree with ‘Base Physio & Performance Run Club (Base Run Club)’ as follows:

1. I acknowledge that I ACCEPT ALL RISKS ASSOCIATED WITH THE ACTIVITY and that such acknowledgment is a condition prior to taking part in any capacity in the Activity.

2. I warrant that I am not presently receiving treatment for any illness, disorder or injury nor am I otherwise aware of any medical or other matter which would render it unsafe for me to take part in the Activity. I am in general good health and have no existing health conditions including but not limited to heart, muscles, bones.

3. I for myself, my executors, administrators and other personal representatives acknowledge that Base Run Club its servants and agents and all persons authorised by it will not be responsible or liable for any claim, cost, loss or expense whatsoever in respect of:

a. any injury to me and including any injury resulting in mental or physical illness whether

temporary or permanent and injury resulting in death;

b. loss of earnings or earning capacity;

c. any impairment of enjoyment of life;

d. loss of or damage to my property and personal belongings;

e. pain and suffering by me; and

f. any loss or damage to a third party of any other kind whatsoever, arising out of my participation in the activity or any act or action whether negligent or otherwise by Base Run Club its servants, agents or authorised representatives and I agree that this Deed may be pleaded in bar to any such claim.

4. I hereby indemnify and will keep Base Run Club, its servants and agents indemnified against any claim, action, proceeding, loss or expense arising out of:

a. any liability for claims by a third party; or

b. any claim I may have, caused by or in connection with my participation in the activity.

5. I authorise Base Run Club and event partners to publish my likeness or matter that identifies me in any material associated with the Activity. I acknowledge I have no copyright in such material.
10
I have read and agree to the terms of the waiver* This field is required.
YESNO
Should be Empty: