registration form - International Association for Suicide Prevention

1333KM
IN 13 DAYS
TO PREVENT SUICIDE
2016
Mon 29 Aug to
Sat 10 Sept 2016
Sri Lanka
Day 2 - Pinnawela
Day 3 - Kandy
Day 4 - Hatton
Day 5 - Nuwera Eliya
Day 6 - Badulla
Day 7 - Polonnaruwa
Day 8 - Trincomalee
Day 9 - Batticloa
Day 10 - Arugam Bay
Day 11 - Kattaragama
Day 12 - Tangalle
Day 1 - Colombo
starting from Colombo
Day 13 - Hikkaduwa
INITIATIVE BY
PROMOTING THE 1333 FREE
& CONFIDENTIAL TELEPHONE
COUNSELLING SERVICE BY CCCLINE
TO PROMOTE
EVENT PARTNERS
finishing in Colombo
Purpose
1333Bikeathon ‘Out of the Shadows’ 2016 is a 13 day bike ride covering 1333km to raise
awareness and funds to support the 1333 toll free number operated by CCCline. CCCline is a free
and confidential telephone counselling service accessible to all people of Sri Lanka who are going
through crisis or simply want to talk about their problems. The ultimate aim of CCCline is to prevent
suicide in Sri Lanka and break the stigma associated with mental illness and some social issues.
What’s Included
- Pre-event training rides and preparation tips
- Twin share accommodation in 3 to 5 star hotels
- Breakfast, lunch and dinner
- Refreshments during ride (drinks & snacks)
- Daily luggage transport during the ride
- Mechanical support and service on-route
- Bike truck and support vehicles
- Police escort on-route
- Medical support including ambulance on-route
Rider Responsibilities
- Adequate training and suitable road bike
- Register and agree to conditions of entry
- Medical checks and personal insurance cover
- Wear 1333Bikeathon branded jersey
- Register on the 1333Bikeathon fundraising
platform and raise funds.
DAY 8: Trincomalee
Key Dates
- Monday 29th August 2016 - Start from
Independence Square, Colombo at 6.30am
- Saturday 10th September 2016 - Finish at
Independence Square, Colombo at 5pm
followed by “World Suicide Prevention Day”
event and closing ceremony
- Part rides are also welcome
DAY 7: Polonnaruwa
DAY 9: Batticaloa
Costs
- Registration & Jersey/T-shirt
- Registration: Rs. 5,000 / AUD $55
includes one Jersey and one T-Shirt
- Additional Jersey at Rs.2,000 / AUD $25
DAY 4: Hatton
DAY 6: Badulla
DAY 10: Arugam Bay
DAY 11: Kataragama
DAY 13: Hikkaduwa
DAY 12: Tangalla
0
400m
135km
215km
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240m
610m
88km
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680m
1,080m
540m
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1,013m
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Elevation Profile (approximate only)
3000m
Kumar Sangakkara
CCC Foundation Ambassador
DAY 5:
Nuwara Eliya
DAY 1: Colombo
- Accommodation, Meals & Supports
- Full 13 Day Ride - Rs.70,000 / AUD $750
- Part Time Ride - Accommodation and meals
will be at cost plus 10% for supports.
Please note all costs only cover direct
expenses of items in “What’s Included.” All
riders are expected to fundraise towards
CCCline through our online platform.
Register online at www.1333bikeathon.org
“I am proud to be part of an
organisation that promotes the
wellbeing of all people of Sri
Lanka. I encourage you to
participate in the 1333Bikeathon
and make a difference to prevent
suicide in Sri Lanka”
DAY 3: Kandy
DAY 2: Pinnawala
262km
348km
500km
147m
233m
620km
765km
560m
880km
607m
365m
1090km
1150km
490m
1233km
1333km
Registration
Closes
30th June 2016
or at max
30 riders
REGISTRATION FORM
29TH AUGUST TO 10TH SEPTEMBER 2016
YOUR DETAILS
NAME:
PHONE:
EMAIL:
ADDRESS:
NAME OF EMERGENCY CONTACT:
PHONE:
RELATIONSHIP:
ANY MEDICAL CONDITIONS:
BLOOD GROUP:
RIDE OPTIONS:
PART OF THE BIKETHON
FULL BIKEATHON - 13 days / 1333 km
I will ride on the following Day(s):
RIDER JERSEY:
SMALL
MEDIUM
LARGE
X LARGE
Number of Extra Jerseys:
(1 Jersey and T-Shirt included with Registration)
(An extra Jersey is Rs.2,000 (AUD $25) each)
(Full time riders are recommended to have 2 jerseys)
PAYMENT DETAILS
(A) Rs.5,000 (AUD$ 55) REGISTRATION FEE
(B) EXTRA JERSEY Rs.2,000 (AUD$ 25)
TOTAL PAYMENT (A+B):
Accommodation, meals and support costs will billed seperately closer to the ride. Please note there will be a limit
of 30 riders in any one day, so please register ASAP to secure a place.
Payment in Sri Lanka:
Bank: Commercial Bank of Ceylon PLC
Branch: Foreign Branch
A/c Name: CCC Foundation Sri Lanka
A/c No: 1030025894
Payment in Australia:
Bank: Westpac Banking Corporation
A/c Name: CCC Foundation
BSB No: 033181
A/C No: 284217
Payment reference:
<your name - bikeathon>
TERMS OF CONDITIONS
These Terms and Conditions of Entry are designed to enable the 1333Bikeathon ‘Out of the Shadows’ (the Ride) from Monday 29th August to Saturday 10th September 2016 to run
smoothly and safely. By registering to participate in the Ride, you (Ride Participant) accept and agree to these Entry Terms as follows: (Ride Participants include Riders, Volunteers,
Staff or anyone who participates in the Ride)
1. If Ride Participant is under the age of 18 years, they must have a Parent or Guardian sign the entry form and consent to their participation in the Ride. It is required that children
under 12 years of age ride with a Parent or Guardian at all times.
2. The Ride Participant must comply with all traffic and road laws and exercise caution and ride defensively and courteously.
3. The Ride Participant must wear an approved bicycle helmet securely fitted and fastened when riding a bicycle during the Ride.
4. The Ride Participant is responsible for ensuring that he/she has adequately prepared both physically and mentally for the Ride.
5. If, during the Ride, the Ride Participant becomes ill or is injured, CCC Foundation will endeavour to call for medical transport, usually an ambulance. Any medical transport will be
at the Ride Participant’s expense. CCC Foundation recommends that Ride Participants hold current ambulance service membership and /or health insurance to cover such costs.
6. The Ride Participant must ride a bicycle that is in a serviceable condition and complies with all relevant legislation.
7. The Ride is held outdoors and will proceed notwithstanding poor weather conditions on the day of the Ride. CCC Foundation is not liable to the Ride Participant for any loss,
damage, cost or expense of any kind including, but not limited to, refund of entry fees, in the event of poor weather before or during the Ride.
8. If the Ride Participant wishes to cancel his/her participation in the Ride, the Ride Participant must notify CCC Foundation in writing, providing his/her name, address, phone
number and reason for cancellation. Written cancellations received before the 30th June will be refunded for their registration fee in full. No refunds are given after the 30th June.
9. CCC Foundation is under no obligation to refund monies or entry fees due to non-use, cancellation, failure to participate or dissatisfaction by the Ride Participant.
10.CCC Foundation may, in its absolute discretion and without giving reasons for its decision, accept or refuse an application for entry.
11.Conduct which, in reasonable opinion of CCC Foundation, is inappropriate may result in the Ride Participant being expelled from the Ride.
12.CCC Foundation is not or liable to the Ride Participant for any loss, damage, cost or expense, whether direct, indirect, incurred by the Ride Participant that may result from any
action taken by CCC Foundation.
13.The Ride Participant understands that during the course of the ride certain risks and dangers may occur, including but not limited to the hazards of riding a bicycle or being in a
motor vehicle, etc. It may also involve accident or illness in remote places, potentially due to the forces of nature, without medical facilities. The Ride Participant agrees to
assume all risks associated with the trip and agrees that no liability will be attached to CCC Foundation or its employees or volunteers, or to any members of the organizing
Committee in the respect of death, personal injury, illness or for any loss of (or damage to) the property of the Ride Participant during the course of the Ride, however caused.
I have read and agree with the terms and conditions of being a registered Ride Participant.
SIGNATURE:
DATE:
Please scan and email this completed form including payment details to jetha@cccfoundation.org.au
For further information send us an enquiry via www.1333bikeathon.org