Name *

First Name

Last Name

Phone *

(###)

###

####

DOB *

MM

DD

YYYY

Division of Entry *

1st choice of division

Open Modern

Open Women's

Open Junior's u/18

Over 35s

Old Mal

Retro

Logger

2nd choice of division

Open Modern

Open Women's

Open Junior's

Over 35s

Old Mal

Retro

Logger

3rd choice of division

Open Modern

Open Women's

Open Junior's u/18

Over 35s

Old Mal

Retro

Logger

Payment Type *

Bank transfer (EFT) details: BSB #633-000 AC #145285441 in the description line of the EFT, please add your first initial and last name.

Online Payment (eftpos/credit card fees apply)

EFT Bank Transfer

Cash at the next MMBC comp

Keen to come but need to confirm details

Agreement *

In consideration of your acceptance of my application to surf at the Crescent Head Malibu Bush to Burbs, I hereby release the sponsors, their members or agents and any official connected with this event from all liability arising from natural cause of otherwise, injuries, illness or (death) ill health whatsoever and howsoever arising from my participation or presence at this contest. I am aware that I am under no obligation to enter the surf and may withdraw from the event at any time if I consider the conditions too dangerous or the location unsuitable. Competitors need to have or take out their own personal accident insurance if they are to be covered for injuries they may obtain. I agree that the Crescent Head Malibu Club & Manly Malibu Boardriders Club retain the right to utilise images of my participation in the event for the purpose of promoting the event. I have read, understood acknowledge and agree to the above declaration.

I agreee