Shipwreck Coast Swim Series

2012 Shipwreck Coast Swim Series

Online Entry Form

First Name:
Surname:
Sex:	Male Female
Date of birth:

Address:

Town:	State: Postcode:

Email:


Please select the swims you wish to participate in:
	PORT FAIRY - MOYNEYANA OCEAN SWIM online entries closed
	PORT CAMPBELL - TWELVE APOSTLES PLUNGE online entries closed
	WARRNAMBOOL - TONY RYAN MEMORIAL SWIM online entries closed

I have read and understood the conditions of entry and hereby agree to all terms.

Please withold my contact details from the Swim Series sponsors.

If you are under 18 years old please complete the following:
Parent's or guardian's full name:

Their contact number:

Major Sponsors

R&D

Minor Sponsor