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*Required information.
Name *
Surname *
Gender *
Birth place *
Birth date *
City *
Address *
Country *
Phone *
E-mail *
Wetsuit *
Club
T-shirt size *

Boat support *
Assistants *

Responsible on the boat:

Name
Phone

I have read and i accept the regulation *
I have read and i accept the disclaimer of liability *

Download disclaimer

I have read and i accept the disclaimer of liability minors

Download disclaimer minors


Indicate the swimming competition, which you took part in the last two years, at least 10 km *
Attach medical certificate

or send it to losevents2015@gmail.com within 07/07/2019.
 
Download medical certificate >>


Payment *