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 [email protected]. 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
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