Surname ___________________________________________

First names _________________________________________

Address ___________________________________________
                ___________________________________________
                ___________________________________________

Tel No. ___________________________________

Sex (M or F) ........ ___ Age on 25/9/11 ... ___

* SAL Reg No. ___________________________________

Club / Team_______________________________________

Entry Fees ( tick appropriate box )

ENTRIES ON THE DAY ONLY.  Cheques should be made payable to Balerno Children's Gala.

Age group trophies, souvenir gift for all finishers and spot prizes.

Refreshment, Changing, Toilet and Bar facilities available at, Malleny Park.
Prize giving at Currie Rugby Club after race

Enquiries: Frank Tooley,  Tel: 0131 453 4213 / 07740 072393 / tooley.frank@gmail.com

Declarations: I hereby declare that on the day of the race I shall be at least 15 year old. I also declare that I am medically fit, and enter at my own risk. I agree that the organisers cannot be held responsible for any loss, injury or illness incurred in connection with this event.

Signed ............................................................. Date ..............................