Entry Form
3rd Masters' International Speed Skating CANADIAN OPEN, Québec/CANADA, 23 - 24 Jan 2010
 
Please fill in this entry form completely and submit it. It will reach the organizer of the competition very fast.
Only use Latin Letters. Entry is expected before 23 Dec 2009 at the latest.
You will be informed by email about the arrival of your entry at the organizer. Additionally a list of entries can be found on the website:  www.fpvq.org
 

Family name

First name

Complete address
(street, no., postal code, town, province, country)

Email address

Telephone

Cellphone

Telefax

Male/female

Date of birth

Starting for Nation

National license no.

Club

Remarks

Waiver:
I hereby declare, that I am in good health and I am properly conditioned for the competitions. By sending this Entry Form electronically to the Organizer I hereby, for myself, my heirs, executors, administrators and assigns, waive and release any and all rights and claims for damages I may have against the Anneau de glace Gaétan Boucher and Québec City, Speed Skating Canada, la Fédération de patinage de vitesse du Québec, the ISU, the IMSSC and other organizations concerned, their agents, officers or members, for any and all injuries suffrered by me at said contest to be held 23 - 24 Jan 2010 in the Anneau de glace Gaétan Boucher, Québec, Canada.

I agree with the waiver
 
    
Several entries:   For sending several entries it may be necessary, not only to press the "Reset"-button and to fill in the form with the data of the following entry and to press again the "Submit"-button, but to reload the entry form for every new entry (depending on the browser used).

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