Kia Tu’ Kia Ora Registration Form
Please note the below before completing the questionnaire
To join the program you cannot have been a Lake City Athletic Club Member for the past three years.
As Rotorua Energy Charitable Trust are providing funding for each program member to attend, its vital to us that you do commit yourself which means attending A MINUMUM of One Clinic Run per week.
Registration Details
Full Name *
Email *
Date of Birth *
Contact Number *
Have you participated in a Rotorua Marathon event before? *
How did you hear about the programme? *
Would you like to fundraise for charity? *
Please provide your T-shirt size *
Are you a Facebook user? *
If yes, what is your Facebook name?
What event are you interested in? *
Which of the below scale best reflects your involvement in exercise *
All details provided must be correct and accurately to record any matters that Athletics NZ needs to be aware of with regard to my health.

Medical Declaration
I am medically and physically fit. I do not suffer from any injury, illness, or condition (physical or mental) that would affect my ability to safely participate in Lake City Athletic Club and other related activities with Athletics NZ.

Athletics NZ can collect, hold, use, and disclose any personal information. (including any photos of me) obtained through this form or as a result of my membership for the following purposes.
a) processing my application for membership and providing services to me
b) publishing photos of me and details about my involvement in any Athletics events, competitions, or activities in Athletics NZ publications (such as websites and newsletters)

All responses will be sent to Annemarie Gallagher, Lake City Athletic Club Marathon Convenor.
I confirm that I have completed this form accurately
I agree to the above declaration
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