| LHHH UMBRAL HASH / POST-UMBRAL HASH WEEKEND | |||||||||||
| Lusaka / Siavonga, Zambia | |||||||||||
| 21 June / 22-24 June 2000 | |||||||||||
| Registration Form | |||||||||||
| Please print ths form and complete it in BLOCK LETTERS and return it to the Lusaka HHH with your International Money Order. Please fax/mail to: Rudy van Gent, P.O. Box 50797, Lusaka, Zambia, E-mail: [email protected], Fax: + 260 1 295377 | |||||||||||
| SIGNING UP FOR: | 1. LHHH Umbral Hash / 2. LHHH Post-Umbral Siavonga Hash Weekend / 3. Both | 1 / 2 / 3 | |||||||||
| Family Surname: | __________________________________________ | Nationality: | __________________________________ | ||||||||
| Given Names: | __________________________________________ | Hash Name: | __________________________________ | ||||||||
| Date of Birth (dd/mm/yy): | __________________________________________ | Passport No: | __________________________________ | ||||||||
| Partners Surname: | __________________________________________ | Nationality: | __________________________________ | ||||||||
| Partners Given Name: | __________________________________________ | Hash Name: | __________________________________ | ||||||||
| Date of Birth (dd/mm/yy): | __________________________________________ | Passport No: | __________________________________ | ||||||||
| Postal address: | __________________________________________ | City: | __________________________________ | ||||||||
| State/County/Province: | __________________________________________ | Postal Code: | __________________________________ | ||||||||
| Country: | __________________________________________ | Home Hash: | __________________________________ | ||||||||
| Telephone: Home: | Int. code | _________ | Area code | __________ | Number | __________________________________ | |||||
| Work: | Int. code | _________ | Area code | __________ | Number | __________________________________ | |||||
| Fax: | Int. code | _________ | Area code | __________ | Number | __________________________________ | |||||
| Cell: | Int. code | _________ | Number | __________________________________ | |||||||
| E-mail address: | __________________________________________________________________________________________ | ||||||||||
| Address/Hotel in Lusaka | __________________________________________________________________________________________ | ||||||||||
| Accommodation Required with Lusaka Hash House Harriers for 20 and 21 June 2000: | No | Yes | |||||||||
| Type of Accommodation Required for LHHH Post-Umbral Hash Weekend 22-24 June 2000: | Chalet | Camping | |||||||||
| T-shirt Size (Umbral Hash) | S / M / L / XL / XXL / XXXL / Other: | __________________________________ | |||||||||
| MODE OF PAYMENT | |||||||||||
| I have enclosed my US$ Money Order | US$ Amount | ____________________ | |||||||||
| I pay by US$ Bank Transfer | US$ Amount | ____________________ | Date of Bank Transfer: | _____________________ | |||||||
| DISCLAIMER | |||||||||||
| I acknowledge that in consideration of my being accepted as a participant of the LHHH Umbral Hash and/or LHHH Post-Umbral Siavonga Hash Weekend, I hereby release all persons and bodies concerned with the organisation and conduct of the LHHH Umbral Hash and/or LHHH Post-Umbral Siavonga Hash Weekend from any claims or actions whatsoever by me or my heirs, executors or assigns, arising from any injury to me or any loss or damage to property associated with my participation in the LHHH Umbral Hash and/or LHHH Post-Umbral Siavonga Hash Weekend. | |||||||||||
| Signed: _______________________________________________________ | Date: | ____________________ | |||||||||
| Fees p.p.: Umbral Hash US$ 35.00 / Weekend (Camping) US$ 95.00 / Weekend (Chalet) US$ 135.00/Extra after 31st March US$ 15.00 | |||||||||||
| Please note that this form is not valid without a signature and a date, and full payment of registration fees! | |||||||||||