USIU-Africa FunRun Registration Form (1)

REGISTRATION FORM
Featuring David Rudisha (800m World Record Holder and Olympic Champion)
Emmanuel Mutai (holds the record for the second-fastest marathon ever run) and
Thomas Longosiwa (bronze medalist at the 2012 London Olympics).
Proceeds from the run will go towards assisting students in need of financial aid.
FIRST NAME:
LAST NAME:
NATIONAL ID/PASSPORT NO:*
STUDENT ID NO:
For child(ren), kindly use his/her guardian’s national ID number or passport number.
EMAIL:
PHONE NO:
GENDER:
FEMALE
DISTANCE:
4.5KM
T-SHIRT SIZE
LARGE
X-LARGE
REG. NO.
11KM
PARTICIPATING AS:
STUDENT
CHILD
ALUMNUS
EMPLOYEE
PARENT
FRIEND OF THE UNIVERSITY
PAYMENT OPTIONS
Select a payment option you would conveniently use to make a contribution to USIU-Africa
M-PESA (LIPA NA MPESA >> PAYBILL:516900>>A/C NAME: FUNRUN)
Cash
(A receipt is issued immediately payment is made.)
Debit Note (Available to students at the Finance Office.)
Cheque (Made payable to USIU-Africa. Please indicate Fun Run at the back of the cheque.)
Thank You!
We appreciate your contribution to participate in the USIU-Africa Fun Run/Walk.
For further information, please email [email protected] or call 0730 116 326 or 0730 116 205