Entry Form - Dragon Canoe Polo

21st Welsh International
Canoe Polo Challenge
6th & 7th August 2016
Cwm Hedd Lakes, Croesheolydd Farm,
Bassaleg, Newport, NP10 8RW
Entry Form
Team Name/ Nom de l’equipe
Ploeg Naam/ Name ihr er Mannschaft
Name, Address/ Nom et adresse
Naam en Adres/ Name und Adresse
E-mail Address
Telephone Number
Open Div 1
Open Div 2
Open Div 3
(Depending on entry level)
Name
Naam
Name
Nom
Number
Nummer
Nummer
Numero
BCU No
Licentie
Genehmigung
Licence
D.O.B.
Geb Datum
Geburtsdatum
Date de naissance
EACH TEAM MUST SUPPLY A QUALIFIED REFEREE
Name of Referee
Grade
COST OF ENTRY / ANMELDEGELD: £75.00 (STERLING)
Cheques should be made payable to:
Bank Transfer with your
Team name as a reference
Closing date for entries:
Dragon Canoe Club
Sort Code 56-00-42
Account No 53591615
17th July 2016
Entries will not be accepted unless accompanied by the correct fee
Maximum number of entries will be 30 teams.
Please return the completed entry form to / Veuillez renvoyer la formulaiore remplie a /
Gelieve Ingevuld Formulieren Terug to Sturren aan / Schicken sie bitte ihre Ausegefuelite anmeldungsformulare
an die nachfolgende adresse
Hywel Whitaker
Canolfan
Windmill Lane
Cowbridge
Vale of Glamorgan
WALES
CF71 7HX
Tel: 07785 371706
E-mail: [email protected]

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