|<style type="text/css">
#hongkiat-form table tr td .clearfix strong {
	color: #F00;
}
#hongkiat-form #recipientcase blockquote table tr td .descr strong {
	color: #F00;
}
#hongkiat-form #recipientcase blockquote table tr td .bold strong {
	font-weight: bold;
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</style>

  <form name="hongkiat" id="hongkiat-form" method="post" action="" enctype="multipart/form-data">
  <div id="exam"></div>
    <div class="clear"></div>
    <table width="80%" border="0" align="center">
      <tr>
		      <td colspan="3"><p><strong><em>INSCRIPCION</em></strong></p></td>
	        </tr>
		    <tr>
		      <td><input class="inp1" type="text" name="rut" id="img6" placeholder="Cédula de Identidad" autocomplete="on" tabindex="3" /></td>
		      <td width="24%"><input class="inp1" type="text" name="club" id="img7" placeholder="Ingresa tu Club Deportivo" autocomplete="on" tabindex="10" /></td>
		      <td width="31%"><input class="inp1" type="text" name="telefono" id="img" placeholder="Numero telefono Obligatorio" tabindex="5"></td>
	        </tr>
		    <tr>
		      <td width="45%">&nbsp;</td>
		      <td width="24%">&nbsp;</td>
		      <td>&nbsp;</td>
	        </tr>
		    <tr>
		      <td><input class="inp1" type="text" name="nombres" id="img2" placeholder="Ingresa tu nombre" autocomplete="on" tabindex="1" /></td>
		      <td><input class="inp1" type="text" name="apellido_paterno" id="img3" placeholder="Ingresa tu Apellido Paterno" autocomplete="on" tabindex="2" /></td>
		      <td><input class="inp1" type="text" name="apellido_materno" id="img4" placeholder="Ingresa tu Apellido Materno" autocomplete="on" tabindex="2" /></td>
	        </tr>
		    <tr>
		      <td>&nbsp;</td>
		      <td>&nbsp;</td>
		      <td>&nbsp;</td>
	        </tr>
		    <tr>
		      <td><input class="inp1" type="text" name="email" id="img5" placeholder="Ingresa tu email" autocomplete="on" tabindex="4" />
		      <td><input class="inp1" type="text" name="ciudad" id="img" placeholder="Ingresa tu Ciudad" autocomplete="on" tabindex="8"></td>
		      <td> <input class="inp1" type="text" name="pais" id="img" placeholder="Ingresa tu Pais" autocomplete="on" tabindex="9"></td>
	        </tr>
		    <tr>
		      <td>&nbsp;</td>
		      <td>&nbsp;</td>
		      <td>&nbsp;</td>
	        </tr>
		    <tr>
		      <td><input class="inp1" type="text" name="banco" id="img" placeholder="Ingresa nombre del banco" autocomplete="on" tabindex="11"></td>
		      <td> <input class="inp1" type="text" name="deposito" id="img" placeholder="N&deg; Trasferencia" autocomplete="on" tabindex="12" ></td>
		      <td><label for="label">
		        <input name="archivo" type="file" class="Estilo3" id="archivo" />
	          </label></td>
	        </tr>
		    <tr>
		      <td>&nbsp;</td>
		      <td>&nbsp;</td>
		      <td>&nbsp;</td>
	        </tr>
		    <tr>
		      <td colspan="3"><span class="clearfix"><strong>POR FAVOR ADJUNTE SU COMPROBANTE DE TRANSFERENCIA O DEPOSITO </strong></span></td>
	        </tr>
		    <tr>
		      <td colspan="3"><section id="recipientcase2">
		        <blockquote>
		          <p>Informaci&oacute;n para transferencia electr&oacute;nica o dep&oacute;sito:<br />
		            <em><strong>Raz&oacute;n social:</strong></em><strong></strong> <em><strong>Club Triatletas Vi&ntilde;a del Mar</strong></em> <br />
		            <em><strong>RUT:&nbsp;  65.807.820 - 8</strong></em><br />
		            <em><strong>Cuenta corriente Banco Estado </strong></em><em><strong>N&uacute;mero 243 0000 6457</strong></em><br />
	              <strong>Correo contacto@triatlonenchile.cl </strong></p>
		        </blockquote>
		        </section>
                  
             </td>
	        </tr>
		    <tr>
		      <td colspan="3" bgcolor="#CCCCCC"><strong>VALORES Y PERIODOS DE INSCRIPCION</strong></td>
      </tr>
		    <tr>
		      <td><p style="color:#F00"> Adultos de 18 a 65 años y más $ 100.000.-<br />
Niños de 7  y jóvenes de 17 años $ 50.000.-<strong><br />
</strong> Relevos Mixtos
	          $ 100.000.- <br />
		      </p></td>
		      <td colspan="2"><p style="color:#F00"><br />
	            <br />
		      </p></td>
      </tr>
		    <tr>
		      <td colspan="3" bgcolor="#FFFFCC"><p><strong>Si el/la  participante, por razones fortuitas o de fuerza mayor, no participare del  evento, el valor de la inscripción no será reembolsada, ni transferida a otro  atleta.</strong><br />
                <strong>Queda estrictamente  PROHIBIDA la entrega de información falsa en el formulario de inscripción, así  como también suplantar la identidad de un corredor, compitiendo con un número  de carrera asignado a otra persona.-</strong></p></td>
      </tr>
    </table>
   <section id="recipientcase">
	    <blockquote>
          <table width="80%" height="87" border="0" align="center">
            <tr>
              <td width="20%">Categoria Competición:</td>
              <td width="2%">&nbsp;</td>
              <td width="22%">Talla Polera:</td>
              <td width="2%">&nbsp;</td>
              <td width="52%">Sexo:</td>
              <td width="2%">&nbsp;</td>
            </tr>
            <tr>
              <td><select id="recipient" name="categoria" tabindex="6" class="selmenu catcomp" style="width: 210px;">
            
                <option value="7 a 9">7 a 9 a&ntilde;os </option>
                <option value="10 a 11">10 a 11 a&ntilde;os </option>
                <option value="12 a 13">12 a 13 a&ntilde;os </option>
                <option value="14 a 15 SuperSprint">14 a 15 a&ntilde;os Super sprint</option>
                <option value="16 a 17 Sprint">16 a 17 a&ntilde;os Sprint</option>
                <option value="18 a 19 Olimpico">18 a 19 a&ntilde;os olímpico</option>
                <option value="20 a 24 Olimpico">20 a 24 a&ntilde;os olímpico</option>
                <option value="25 a 29 Olimpico">25 a 29 a&ntilde;os olímpico</option>
                <option value="30 a 34 Olimpico">30 a 34 a&ntilde;os olímpico </option>
                <option value="35 a 39 Olimpico">35 a 39 a&ntilde;os olímpico </option>
                <option value="40 a 44 Olimpico">40 a 44 a&ntilde;os olímpico </option>
                <option value="45 a 49 Olimpico">45 a 49 a&ntilde;os olímpico</option>
                <option value="50 a 54 Olimpico">50 a 54 a&ntilde;os olímpico </option>
                <option value="55 a 59 Olímpico">55 a 59 a&ntilde;os olímpico </option>
                <option value="60 a 64 Olímpico">60 a 64 a&ntilde;os olímpico </option>
                <option value="65mas Olimpico">65 y m&aacute;s a&ntilde;os olimpico </option>
                <option value="18 a 65mas–promocional sprint">18 a 65 años y más promocional sprint</option>
                
                <option value="Relevos_Mixtos">Relevos Mixtos Olimpicos</option>
           </select></td>
              <td>&nbsp;</td>
              <td><span class="radiobadge">
                <input type="radio" id="low2" name="talla" value="S" />
                <label for="low2">S</label>
              </span> <span class="radiobadge">
              <input type="radio" id="med2" name="talla" value="M" />
              <label for="med2">M</label>
              </span> <span class="radiobadge">
              <input type="radio" id="high" name="talla" value="L" />
              <label for="high">L</label>
              </span> <span class="radiobadge">
              <input type="radio" id="high" name="talla" value="XL" />
              <label for="high">XL</label>
              </span></td>
              <td>&nbsp;</td>
              <td><span class="radiobadge">
                <input type="radio" id="low" name="sexo" value="V" />
                <label>Varon</label>
              </span> <span class="radiobadge">
              <input type="radio" id="med" name="sexo" value="D" />
              <label>Dama</label>
              </span></td>
              <td>&nbsp;</td>
            </tr>
            <tr>
              <td>&nbsp;</td>
              <td>&nbsp;</td>
              <td>&nbsp;</td>
              <td>&nbsp;</td>
              <td>&nbsp;</td>
              <td>&nbsp;</td>
            </tr>
            <tr>
              <td>Fecha Nacimiento:</td>
              <td>&nbsp;</td>
              <td>&nbsp;</td>
              <td>&nbsp;</td>
              <td>&nbsp;</td>
              <td>&nbsp;</td>
            </tr>
            <tr>
              <td><select name="dia" style="width:40px" id="dia" >
                                <option value="01">
                  01                </option>
                                <option value="02">
                  02                </option>
                                <option value="03">
                  03                </option>
                                <option value="04">
                  04                </option>
                                <option value="05">
                  05                </option>
                                <option value="06">
                  06                </option>
                                <option value="07">
                  07                </option>
                                <option value="08">
                  08                </option>
                                <option value="09">
                  09                </option>
                                <option value="10">
                  10                </option>
                                <option value="11">
                  11                </option>
                                <option value="12">
                  12                </option>
                                <option value="13">
                  13                </option>
                                <option value="14">
                  14                </option>
                                <option value="15">
                  15                </option>
                                <option value="16">
                  16                </option>
                                <option value="17">
                  17                </option>
                                <option value="18">
                  18                </option>
                                <option value="19">
                  19                </option>
                                <option value="20">
                  20                </option>
                                <option value="21">
                  21                </option>
                                <option value="22">
                  22                </option>
                                <option value="23">
                  23                </option>
                                <option value="24">
                  24                </option>
                                <option value="25">
                  25                </option>
                                <option value="26">
                  26                </option>
                                <option value="27">
                  27                </option>
                                <option value="28">
                  28                </option>
                                <option value="29">
                  29                </option>
                                <option value="30">
                  30                </option>
                                <option value="31">
                  31                </option>
                              </select>
                <select name="mes" style="width:40px"  id="mes" >
                                    <option value="01">
                    01                  </option>
                                    <option value="02">
                    02                  </option>
                                    <option value="03">
                    03                  </option>
                                    <option value="04">
                    04                  </option>
                                    <option value="05">
                    05                  </option>
                                    <option value="06">
                    06                  </option>
                                    <option value="07">
                    07                  </option>
                                    <option value="08">
                    08                  </option>
                                    <option value="09">
                    09                  </option>
                                    <option value="10">
                    10                  </option>
                                    <option value="11">
                    11                  </option>
                                    <option value="12">
                    12                  </option>
                                  </select>
              <input name="fecnac" type="text" id="fecnac" size="6" maxlength="4" /></td>
              <td>&nbsp;</td>
              <td>&nbsp;</td>
              <td>&nbsp;</td>
              <td>&nbsp;</td>
              <td>&nbsp;</td>
            </tr>
            <tr>
              <td>&nbsp;</td>
              <td>&nbsp;</td>
              <td>&nbsp;</td>
              <td>&nbsp;</td>
              <td>&nbsp;</td>
              <td>&nbsp;</td>
            </tr>
            <tr>
              <td><div class="descr" align="justify"><strong>Declaraci&oacute;n Jurada: </strong></div></td>
              <td>&nbsp;</td>
              <td>&nbsp;</td>
              <td>&nbsp;</td>
              <td>&nbsp;</td>
              <td>&nbsp;</td>
            </tr>
            <tr>
              <td colspan="6"><strong><em>Declaro encontrarme en  óptimas condiciones tanto físicas como mentales para participar en el &ldquo;</em>28º TRIATLON INTERNACIONAL VIÑA DEL MAR 2025&quot;<em>, a realizarse el día 19 de Abril de  2025, eximiendo de toda responsabilidad a los organizadores y entidades  patrocinadoras y auspiciadoras por accidentes que pueda tener antes, durante o  después de la competencia. Además declaro conocer las bases y&nbsp; el  reglamento&nbsp;de la competencia.</em></strong></td>
            </tr>
            <tr>
              <td>&nbsp;</td>
              <td>&nbsp;</td>
              <td>&nbsp;</td>
              <td>&nbsp;</td>
              <td>&nbsp;</td>
              <td>&nbsp;</td>
            </tr>
            <tr>
              <td><input name="acepto" type="checkbox" id="acepto" value="acepto" />
              <span class="bold"><strong>Acepto</strong></span></td>
              <td>&nbsp;</td>
              <td>&nbsp;</td>
              <td>&nbsp;</td>
              <td>&nbsp;</td>
              <td>&nbsp;</td>
            </tr>
            <tr>
              <td>&nbsp;</td>
              <td>&nbsp;</td>
              <td>&nbsp;</td>
              <td>&nbsp;</td>
              <td>&nbsp;</td>
              <td>&nbsp;</td>
            </tr>
            <tr>
              <td><input type="submit" name="Enviar" id="submitbtn" class="submitbtn" tabindex="7" value="Enviar" /></td>
              <td>&nbsp;</td>
              <td>&nbsp;</td>
              <td>&nbsp;</td>
              <td>&nbsp;</td>
              <td>&nbsp;</td>
            </tr>
          </table>
          <p>&nbsp;</p>
       </blockquote>
    </section>
</form>

 </div>