ENTRY FORM – Namaqua Quest Trail Running Stage Race Step 1 of 3 - Personal Information 33% Payment OptionFull Payment NowPayment Plan - Deposit now, followed by 2 paymentsFull Payment or Payment Plan. Please note, no refunds on deposits paid.Start Your RegistrationEvent Registration FULL PAYMENT VAT Excl.Stage Race - R2800Stage Race LITE - R25002-Day Stage Race R1950Single Day (Sunday) – R3002 or 3 Day Run through the world's most beautiful natural flower display. Trails through flower covered valleys, ancient mountains and canyons carved by the hands of time.Event Registration PAYMENT PLAN VAT Excl.Stage Race - R2800Stage Race LITE - R25002 Day Stage Race R1950Single Day (Sunday) – R3002 or 3 Day Trail Run through the world's most beautiful natural flower display. Trails through flower covered valleys, ancient mountains and canyons carved by the hands of time.MerchandiseMeal Package FULL PAYMENT VAT Excl.No Meal PackageMeal Package R1200R1,200.00 per person (the meal package can also be booked for family and supporters) Includes all meals from Friday Breakfast to Sunday Lunch.Meal Package PAYMENT PLAN VAT Excl.No Meal PackageMeal Package R1200R1,200.00 per person (the meal package can also be booked for family and supporters) Includes all meals from Friday Breakfast to Sunday Lunch.Springbok Inn Country Hotel Accommodation FULL PAYMENT VAT Excl.No AccommodationDouble Room with double bed R2850Twin Room with two single beds R2850Hotel Room (Twin or Double) R2850.00 Camp Site R510.00 (sleeps 4) (FULL)Springbok Inn Country Hotel Accommodation PAYMENT PLAN VAT Excl.No AccommodationDouble Room with double bed R2850Twin Room with two single beds R2850Hotel Room (Twin or Double) R2850.00 Camp Site R510.00 (sleeps 4) (FULL)VAT Price: R0.00 Total R0.00 Personal InfoEmail* Name* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Mobile Phone*Date of Birth* Date Format: YYYY slash MM slash DD Gender*MaleFemaleNationality* AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Emergency Contact Name* First Last Emergency Contact Telephone*ID Number*Age Category*Junior (11 - 17 years old)Senior (18 to 39 years old)Veteran (40 - 49 years old)Master (50 years old and up)Shirt Size*Extra SmallSmallMediumLargeExtra LargeExtra Extra LargeVegetarian*YesNoHow many Namaqua Quest events have you participated in? Indemnity* I agree By agreeing, I hereby waive any claim which can be made against the shareholders, directors and staff of Chime, CSM Sport & Entertainment SA, Springbok Country Inn Hotel or temporarily staff on the event or any private lodge, home owner or farm owner associated with the event or any other governmental body not mentioned here, or any sponsor associated with the event(Hereinafter referred as the INDEMNIFIED PERSONS), which may arise from any activities offered by the INDEMNIFIED PERSONS and specifically with regard to this Event. The INDEMNITY GRANTOR hereby releases the INDEMNIFIED PERSONS from all liability and holds each and all the INDEMNIFIED PERSONS harmless against all claims, damages, injuries, losses, debts, expenses and liabilities arising out of or in any way connected with any activities offered by the INDEMNIFIED PERSONS, including without limitation: 1. Any personal injury or loss of life; 2. Any loss of support, maintenance or other claims or damages arising from or connected with any personal injury or loss of life to the INDEMNITY GRANTOR; and 3. Any loss or damage to property belonging to the INDEMNITY GRANTOR or any third party, which may occur whilst participating in the said race; 4. Whether arising out of strict liability, statute or otherwise and whether caused by the negligence on the part of the INDEMNIFIED PERSONS or any other person or otherwise I am fully aware of the dangers associated with this event and of the dangers to which we will expose myself during the event. I am fully aware of the possibility of human interference other than that of the organizers and the INDEMNITY GRANTOR fully accepts all the risks associated therewith. I acknowledge that I am aware that trail running and mountain biking are dangerous activities on off-road terrain and there are significant risks involved which can lead to severe trauma, injury and loss of life. I further acknowledge that the race may be stopped on the organisers discretion if the conditions become too dangerous in their opinion. I hereby undertake to always follow their instructions and I accept that failure to do so on my part will expose me to potential severe injuries or loss of life. During the event, children should always be under parent supervision IMDENNIFIED PERSONS will be indemnified and held harmless against all claims, damages, injuries, losses, debts, expenses and liabilities arising out of or in any way connected with any children activities offered by the INDEMNIFIED PERSONS. I declare that I am physically fit and healthy so far as may reasonably be determined and undertake to inform the organizers and their team of any condition, medical or otherwise past and/or present, which may have an impact on my participation and the participation of others in the aforesaid activities. Each clause of this Deed of Indemnity is independent and severable from all other clauses. The acknowledgements, agreements and undertakings in this indemnity shall be deemed to be made in favour of the INDEMNIFIED PERSONS. Each element of the release from liability and/or indemnity in respect of each cause or activity covered by this release from liability and/or indemnity shall be separate and severable from the other elements. This indemnity shall in all respect be governed by the Laws of the Republic of South Africa, and all disputes actions and other matters arising in connection herewith, shall be determined in accordance with such laws. NameThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.
