Africa Wild Ultra Registration

Step 1 of 4

Which Race Are You Interested In?

257km Ultra Marathon 21km Half Marathon

Please select a race distance

Number of Tickets *

Please select number of tickets

Personal Information

First Name *

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Last Name *

Please enter your last name

Email *

Please enter a valid email address

Phone Number *

Please enter your phone number

Date of Birth *

Please enter your date of birth

Gender *

Please select your gender

Country *

Please select your country

Biography (Optional)

Race Type *

Please select race type

T-Shirt Size *

Please select your t-shirt size

Emergency Contacts

Next of Kin

Next of Kin Name *

Please enter next of kin name

Next of Kin Phone *

Please enter next of kin phone

Next of Kin Email *

Please enter next of kin email

Relationship to Next of Kin *

Please enter relationship

Medical Information

Doctor's Name *

Please enter doctor's name

Doctor's Phone *

Please enter doctor's phone

Doctor's Email *

Please enter doctor's email

Medical Aid/Insurance Provider *

Please enter medical aid provider

Medical Aid Number *

Please enter medical aid number

Medical Aid Member *

Please enter medical aid member name

Medical Aid Contact Number *

Please enter medical aid contact

Medical History *

Please enter medical history information

Review & Confirm

Terms & Conditions

I confirm I have read and agree to the Terms and Conditions *

I grant Africa Wild Ultra™ permission to use my image in marketing materials

Confirm you are older than 18 years of age *

Which RACE are you interested in?*

257km Ultra Marathon R25 000 R22 500

21km Half Marathon R850 R765

Which RACE are you interested in?*

257km Ultra Marathon $3 000 $2 700

21km Half Marathon $80 $72

Personal Information

First Name*Last Name*Email*Number*Date of birth*Gender*Country*Biography

Race Type*

Team Name

CHARITY AFFILIATION

CHARITY NAME

Emergency Contacts

NExt of kin NAmE*NExt of kin PHONE*NExt of kin EMAIL*Relationship to next of kin*

Medical Information

Doctor's name*Doctor's Phone*Doctor's Email*Medical aid/insurance provider*Medical aid Number*Medical aid member*MEdical aid contact number*MEdical HISTORY*

Terms & Conditions

I confirm I have read and agree to the Terms and Conditions*I grant Africa Wild Ultra™ permission to use my image in marketing materials*Confirm you are older than 18 years of age*

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ONLINE COMPETITOR REGISTRATION FORM

Which Race Are You Interested In?

Personal Information

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-10% Discount