2021 Longmore Forest Endurance Run – 50 Mile

First Name: *

Last Name: *

Email: *

Mobile Number: *

Gender: * Male Female

Age: *

Date Of Birth (YYYY-MM-DD): *

ID Number: *

Emergency Contact Person: *

Emergency Contact Number: *

Allergies: *

Any medical conditions we should know about?: *

Medical Aid: *

Medical Aid Number: *

Family Doctor: *

Doctors Telephone Number: *

Do you use any performance enhancing medication?: * Yes No

Are you currently taking any medication (chronic or otherwise)?: * Yes No

Do you suffer from any of the following? (tick all that apply): Cardiovascular problems Respiratory problems Endocrine problems (diabetes) Musculoskeletal problems Central nervous system problems (fainting or epilepsy etc) Major illness within the last year Gastro intestinal problems Any family history of heart disorders

If you answered Yes to any of the above, please supply details:

If you have undergone any surgical procedures in the last 2 years, please supply details:

If you have ever suffered from a heart disorder or anaesthetic problem, please supply details:

What is your blood type?:

Race garment (top) size: * Ladies XS Ladies S Ladies M Ladies L Ladies XL Ladies XXL Mens XS Mens S Mens M Mens L Mens XL Mens XXL

Country: * RSA - South Africa AFG - Afghanistan ALB - Albania ALG - Algeria ASA - American Samoa AND - Andorra ANG - Angola AIA - Anguilla ANT - Antigua and Barbuda ARG - Argentina ARM - Armenia ARU - Aruba AUS - Australia AUT - Austria AZE - Azerbaijan BAH - Bahamas BRN - Bahrain BAN - Bangladesh BAR - Barbados BLR - Belarus BEL - Belgium BIZ - Belize BEN - Benin BER - Bermuda BHU - Bhutan BOL - Bolivia BIH - Bosnia and Herzegovina BOT - Botswana BRA - Brazil BRU - Brunei Darussalam BUL - Bulgaria BUR - Burkina Faso BDI - Burundi CAM - Cambodia CMR - Cameroon CAN - Canada CPV - Cape Verde CAY - Cayman Islands CAF - Central African Republic CHA - Chad CHI - Chile TPE - Chinese Taipei COL - Colombia COM - Comoros CGO - Congo COK - Cook Islands CRC - Costa Rica CIV - Côte d'Ivoire CRO - Croatia CUB - Cuba CYP - Cyprus CZE - Czech Republic PRK - Democratic People's Republic of Korea COD - Democratic Republic of the Congo TLS - Democratic Republic of Timor-Leste DEN - Denmark DJI - Djibouti DMA - Dominica DOM - Dominican Republic ECU - Ecuador EGY - Egypt ESA - El Salvador GEQ - Equatorial Guinea ERI - Eritrea EST - Estonia ETH - Ethiopia FSM - Federated States of Micronesia FIJ - Fiji FIN - Finland FRA - France PYF - French Polynesia GAB - Gabon GAM - Gambia GEO - Georgia GER - Germany GHA - Ghana GIB - Gibraltar GBR - Great Britain GRE - Greece GRN - Grenada GUM - Guam GUA - Guatemala GUI - Guinea GBS - Guinea-Bissau GUY - Guyana HAI - Haiti HON - Honduras HKG - Hong Kong (China) HUN - Hungary ISL - Iceland IND - India INA - Indonesia IRQ - Iraq IRL - Ireland IRI - Islamic Republic of Iran ISR - Israel ITA - Italy JAM - Jamaica JPN - Japan JOR - Jordan KAZ - Kazakhstan KEN - Kenya KIR - Kiribati KOS - Kosovo KUW - Kuwait KGZ - Kyrgyzstan LAO - Lao People's Democratic Republic LAT - Latvia LBN - Lebanon LES - Lesotho LBR - Liberia LBA - Libya LIE - Liechtenstein LTU - Lithuania LUX - Luxembourg MAC - Macao MAD - Madagascar MAW - Malawi MAS - Malaysia MDV - Maldives MLI - Mali MLT - Malta MHL - Marshall Islands MTN - Mauritania MRI - Mauritius MEX - Mexico MON - Monaco MGL - Mongolia MNE - Montenegro MNT - Montserrat MAR - Morocco MOZ - Mozambique MYA - Myanmar NAM - Namibia NRU - Nauru NEP - Nepal NED - Netherlands NZL - New Zealand NCA - Nicaragua NIG - Niger NGR - Nigeria NFI - Norfolk Island NMI - Northern Mariana Islands NOR - Norway OMA - Oman PAK - Pakistan PLW - Palau PLE - Palestine PAN - Panama PNG - Papua New Guinea PAR - Paraguay CHN - People's Republic of China PER - Peru PHI - Philippines POL - Poland POR - Portugal PUR - Puerto Rico QAT - Qatar KOR - Republic of Korea MDA - Republic of Moldova ROU - Romania RUS - Russian Federation RWA - Rwanda SKN - Saint Kitts and Nevis LCA - Saint Lucia SAM - Samoa SMR - San Marino STP - Sao Tome and Principe KSA - Saudi Arabia SEN - Senegal SRB - Serbia SEY - Seychelles SLE - Sierra Leone SGP - Singapore SVK - Slovakia SLO - Slovenia SOL - Solomon Islands SOM - Somalia SSD - South Sudan ESP - Spain SRI - Sri Lanka VIN - St Vincent and the Grenadines SUD - Sudan SUR - Suriname SWZ - Swaziland SWE - Sweden SUI - Switzerland SYR - Syrian Arab Republic TJK - Tajikistan THA - Thailand MKD - The Former Yugoslav Republic of Macedonia TOG - Togo TGA - Tonga TTO - Trinidad and Tobago TUN - Tunisia TUR - Turkey TKM - Turkmenistan TKS - Turks and Caicos Islands TUV - Tuvalu UGA - Uganda UKR - Ukraine UAE - United Arab Emirates TAN - United Republic of Tanzania USA - United States of America URU - Uruguay UZB - Uzbekistan VAN - Vanuatu VEN - Venezuela VIE - Vietnam IVB - Virgin Islands (British) ISV - Virgin Islands (US) YEM - Yemen ZAM - Zambia ZIM - Zimbabwe

Shoe size: *

Current shoe brand: *