Event: o 1.2Km swim o 10Km Swim
Category: Male Womens
o 1.2K Junior 12—17Yrs o 1.2K Junior 12-17Yrs
o 1.2K Adult 18-35Yrs o 1.2K Adult 18-35Yrs
o 1.2K Masters Over 35Yrs o 1.2K Masters Over 35Yrs
o 5 K open  (minimum age 15yrs) o 10K Open (minimum age 15yrs)
o 10K Open (minimum age 15yrs) o 10K Open (minimum age 15yrs)Given Name: __________________________________________________________________________________
Family Name __________________________________________________________________________________
Nationality ________________________ I.D No (for Indonesian Citizens/Residents Only) _____________
Gender o M o F
Date of Birth ____________________________________ Age on Race Day: _____________________________
Address ___________________________________________________________________________________
Country of Residence ____________________________
Email contact ___________________________________________________________________________________
Phone No. ____________________________________
Mobile (hand phone) ________________________________
Emergency Contact 1.________________________________ 2. ___________________________________
Emergency Phone 1. _______________________________ 2. ___________________________________
List Previous Experience at Registered Distance: ___________________________________________________________
_________________________________________________________________________________________________
Current Medical Problems: ___________________________________________________________________________
_________________________________________________________________________________________________
Are you allergic to any medication? ___________________________________________________________________
_________________________________________________________________________________________________
Do you wish medical sta to be aware of any condition? o Yes o No
If Yes, please detail: _________________________________________________________________________________
I certify that I am medically t to compete and fully understand that I enter at my own risk, and that the organizers
will in no way be held responsible for any injury, illness or loss, during or as a result of the event.
Signed ______________________________ Date: _________________________________

2012 Entry Fees 

Indonesian & KITAS holder 



1,2 km = 250.000
 5 km = 450.000
10 km = 750.000



For all other swimmers

1,2 km = $  40
   5 km = $  70
 10 km = $  90 


Payment to 


Bank Details

Account Name: Yayasan Damai Olahraga Bali
Bank: CIMB Niaga
Branch: Jl Melati, Denpasar, Bali

Rupiah: 1310100211006
USD: 1310200004008

there is a 20% late payment fee,if paid within 2 weeks of event.

Please scan fill out entry and copy of TT (money transfer) and email to info@balioceanswim.com