Registration INDEMNITY Release the waiver In consideration of the acceptance of my entry I, for myself, executors, heirs, administrators and assigns, do hereby release and discharge Western Province Aquatics and their designated organisers and all their sponsors, Clifton Surf Lifesaving Club and their representatives, and all voluntary groups, all medical personnel, and all authorities from all claims for injuries, damage and property loss I may suffer, caused by negligence of any of them and arriving out of my participation in the event, including pre- and post-race activities. It is my responsibility independently to acquaint myself and my support crew fully with the risks and hazards of long distance open-water swimming (and in particular the Swim) and I have done so. I am physically fit and sufficiently trained to participate in this event and assume all risks for participation. I undertake the Swim with full knowledge and appreciation that long-distance coldwater swimming in the ocean is inherently hazardous. I accept all such hazards and risks. I accept all rules, conditions and regulations, which include terms of payment of the entry fees and will comply with them. I also grant my permission to Western Province Aquatics, the race organisers and their authorised agents to use my name, photographs, video tapes, broadcasts, telecasts, advertising, promotion or other account of this event, free of charge. This waiver and indemnity, once signed, is irrevocable and shall continue to operate hereafter in respect of all open-water swims in which I participate and in which the organiser is involved in any capacity. By submitting this entry form, I accept the terms and conditions, as set out above.*YesNoSplitter1Username*Password*Confirm Password*Splitter2Personal DetailsFirst Name*Known AsLast Name*Gender*Email Address*Phone Number*CountryAfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongoCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly See (Vatican City State)HondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKoreaKoreaKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyan Arab JamahiriyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussian FederationRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyrian Arab RepublicTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVenezuelaViet NamVirgin IslandsVirgin IslandsWallis and FutunaWestern SaharaYemenZambiaZimbabweNational Identification Number (ID or Passport)*Date of Birth*Splitter3Opt in to receiving Communication regarding swimsYesNoSplitter4Medical InformationPlease briefly list any medical conditions you have, that a first aider should know about, in the case of an emergency. If none, Please state 'None'.*Emergency Contact*Emergency Contact Number*Medical Aid Plan*Medical Aid Number*Splitter5Optional InformationSwimming CoachMembership of ClubsAccomplishments and AchievementsNumber of Years SwimmingEstimated swim times (100m) (hh:mm:ss)Estimated swim times (400m) (hh:mm:ss)Estimated swim times (1500m) (hh:mm:ss)Register Error occured. Please confirm your data and submit again: