Printable Individual & Family Registration Form

Ride 2 Riverstone 2015 Individual & Family Entry Form
Help support the Australian Lions Childhood Cancer Research Foundation
First Name
Surname
Address
Suburb
Phone – Home
Mobile
Email Address
Are you a member of a bike club ? YES/NO
State
Post Code
Work
Club
Entry Fees
Until
20/04/2015
After
20/04/2015
Adult
Under 18 (as at 01/05/2015)
Concession (as per conditions)
Family (see below)
Volunteer (Signage Crew)
$60.00
$30.00
$35.00
$140.00
Free
$70.00
$30.00
$45.00
$160.00
Free
Total
Number
Total
Concession -
Pension/Senior/Tertiary Card Holders Only. The card must be presented when
collecting your event documentation at the start.
Signage Crew Vol –
You will need to be available to help setup for several hours the day before the
event to secure your free entry.
Family Members –
Please list the additional riders for this entry. Note that children under 16 must be
under direct adult supervision. A family entry consists of up to 6 members, with no
more than 2 adults, and the primary entrant being over 18 years of age.
Name
Lunch Options
Entries Close
Relationship
Standard Lunches
__________
Date of Birth
Vegetarian
__________
4.00pm 01/05/2015 for mailed or emailed entries.
Scan and Email completed entry forms to info@ride2riverstone.com.au.
Postal Address : Riverstone and District Lions Club, PO Box 158, Riverstone NSW 2765
On the day entries are available between 6.30am and 8.15am at the start site.
Riverstone and District Lions Club, PO Box 158, Riverstone NSW 2765
Payment
Payments can be made by Cheque, MasterCard, Visa or direct deposit for preregistrations. Cash, Eftpos and Credit card facilities will be available for on the day
registrations.
Please select a payment type
Direct Deposit -
Cheque Credit Card -
Please use your first initial and your last name as reference.
Account details - BSB: 062 596
ACC: 1011 1042
Please mail or scan and email your completed entry forms.
Payable to ‘Riverstone and District Lions Club Inc. Cycle Event’.
Please post your completed entry from and cheque.
MasterCard and
Visa only
Card Holder ________________________ Card No. _____________________
Expiree Date ____/____ (MM/YY)
Conditions of entry
1.
2.
3.
4.
5.
6.
7.
8.
By entering this ride, you agree to abide by the Australian Road Rules, including wearing an Australian Standards
AS/NZS 2063 approved helmet at all times while riding.
You agree to obey the directions of any of the Route Marshals &/or Ride Officials.
Carry adequate drinking water; wear/carry clothing appropriate to the prevailing conditions of the day.
Carry adequate items to repair a puncture (eg tyre levers, pump, spare tube of the correct size, patch kit, and a
wheel nut spanner or multi-tool if required).
You need to ensure that your bike is mechanically sound.
You have the fitness and skills needed to complete successfully and safely, the distance you have entered.
I/we have entered to join the bike ride activity of Riverstone & District Lions Club Inc.
rd
I/we wish to participate in the bike ride on Sunday 3 May, 2015
I hereby waive all and any claims, or cause of action which I might be entitled to have against all officers, personnel,
officials, organizers and any person whatsoever involved in the Lion’s Club’s bike ride and other participants who may be
liable for any damage in respect of any matter whatsoever arising out of / or incidental to the event (bike ride), whether or
not such act or omission by such aforesaid Lion’s personnel is either negligent or reckless. I hereby give my consent for the
appointed doctors, staff and other officials of Riverstone & District Lions Club Inc. to provide first aid and deliver me for
treatment at the nearest operating and available medical facility in case I am injured as a result of the bike ride activity or
event which I am part of or involved with.
I/we, __________________________________________ have read and understood this form.
_______________________________________________(Signature)
Date ____/____/____
For more information on the event please refer to our web site www.ride2riverstone.com.au or Facebook
page.
We welcome Volunteers!
Please register online.
Riverstone and District Lions Club, PO Box 158, Riverstone NSW 2765