Boileau Velo COAST TO COAST REGISTRATION FORM SUNDAY 22 MARCH 2015 BICYCLE SA 23 Carrington Street Adelaide SA 5000 Phone +61 8 8168 9999 Fax +61 8 8168 9988 [email protected] www.bikesa.asn.au COMPLETE DETAILS BELOW AND FAX TO 8168 9988 or email to [email protected] Please complete a separate form for each participant/family member (photocopies accepted). Please ensure that all information is filled out clearly using block letters. All prices quoted are in Australian dollars. PERSONAL DETAILS DISTANCES TITLE SURNAME FIRST NAME MALE FEMALE DATE OF BIRTH TAX INVOICE ABN 65 508 272 584 GLENELG 120km 7:30am START STIRLING 95km 8:00am START MEADOWS 65km 8:00am START MINI COAST TO COAST 10km/20km 10:00am START ADDRESS (POSTAL) EVENT JERSEY (OPTIONAL – ONLY $59) SUBURB To PURCHASE your exclusive event jersey for ONLY $59, add to TOTAL and select your CHEST SIZE (CENTIMETRES) below. STATE POSTCODE TELEPHONE (HOME) 2XS (80) M (95) 2XL (110) XS (85) L (100) 3XL (115) S (90) XL (105) 4XL (120) 5XL (125) TELEPHONE (MOBILE) EMAIL See website for design. COACH TRANSFERS - RIDER & BIKE TO START OR FROM FINISH TEAM NAME I WOULD LIKE THE FOLLOWING COACH TRANSFER (FOR RIDER AND BIKE) TEAM CAPTAIN ADELAIDE TO STIRLING $50 DEPART 6.30AM EMERGENCY CONTACT NAME ADELAIDE TO MEADOWS $60 DEPART 6.30AM VICTOR HBR TO GLENELG $60 DEPART 1.30PM 3PM VICTOR HBR TO STIRLING $60 DEPART 1.30PM 3PM VICTOR HBR TO MEADOWS $50 DEPART 1.30PM 3PM EMERGENCY CONTACT TELEPHONE MEDICAL CONDITIONS / ALLERGIES: PRE PAID TICKETS ONLY (MUST BE PAID WITH REGISTRATION FEE) VEGETARIAN MEAL REQUIRED? DONATION OTHER DIETARY REQUIREMENTS? ARE YOU A BICYCLE SA MEMBER? YES I WISH TO MAKE A TAX DEDUCTABLE DONATION TO THE SMITH FAMILY (RECEIPT SENT DIRECTLY FROM AGF) MEMBERSHIP NO. NO $10 $25 IF NOT, I WOULD LIKE TO JOIN BICYCLE SA (OR RENEW) AS THE FOLLOWING TYPE OF MEMBER; PAYMENT DETAILS INDIVIDUAL $80 TOTAL - $ INDIVIDUAL CONCESSION $57 HOUSEHOLD $110* HOUSEHOLD CONCESSION $77* * PLEASE INCLUDE THE NAMES & DATES OF BIRTH OF ALL HOUSEHOLD MEMBERS $75 $100 $250 ALL PRICES INCLUDE GST PLEASE MAKE CHEQUE/MONEY ORDER PAYABLE TO BICYCLE SA CREDIT CARD DETAILS VISA MASTERCARD EXP ENTRY FEES (JERSEY NOT INCLUDED) COAST TO COAST $50 VERIFICATION CODE CARD HOLDER’S NAME (GRANDE 120km /CLASSIC 95km/CHALLENGE 65km) BSA MEMBER NON MEMBER ADULT $69 $85 CHILD 6 -16YRS $40 $40 MINI COAST TO COAST (ALONG THE ENCOUNTER BIKEWAY) BSA MEMBER NON MEMBER ADULTS $15 $20 CHILDREN 6 -16YRS $10 $10 CHILDREN 5 AND UNDER FREE CARD HOLDER’S SIGNATURE TERMS & CONDITIONS OF ENTRY (see full details on next page) The event terms and conditions apply to all participants (as a cyclist or otherwise) in the Boileau Velo Coast to Coast (Event), and in the case of a child under the age of 16, the parent or legal guardian of the participant. In consideration of my participation in the Event, I warrant and represent to Bicycle SA that I have carefully read, understand and agree to be bound by the full schedule of terms and conditions as listed on the Event website We encourage participants to support those companies that support Bicycle SA. However, if you DO NOT wish to receive information from our sponsors please mark with an X. I have read carefully and agree to the conditions of entry. SIGNED *** PLEASE COMPLETE SEPARATE FORMS FOR EACH FAMILY MEMBER SIGNED BY PARENT OR GUARDIAN IF ENTRANT UNDER 18 YEARS OF AGE Please complete separate forms for each participant/family member. Full Terms & Conditions I understand that participation in this Bicycle SA ride involves riding on public roads used by other traffic. I am aware of the hazards involved and I agree to obey the road rules. I/the child in my care has sufficient experience and competence to participate safely in the ri de and I hereby release and forever discharge, exempt and indemnify the organiser, sponsors and all other persons involved in the organisation, from all action, proceedings, demands and claims whatsoever taken by any participation in the ride. Bicycle SA reserves the right to refuse entry. Bicycle SA reserves the right to alter or amend the route due to road, weather and other operational needs prevailing at the time and it is always made in the best interest of participant safety. Persons under the age of 16 must be accompanied by and in the care of a nominated adult who is responsible for them throughout the event. Bicycle SA shall not be liable or responsible for any direct, indirect, consequential or accidental damage, injury, loss, accident, delay or irregularity of an y kind which may be occasioned by reason of any act or omission of any third party. Without limiting the foregoing, Bicycle SA does not own or operate any third party suppliers of services such as hotels, restaurants, or transportation companies. Bicycle SA is not responsible for any injury, death or loss. Any expenses must be borne by the participant. Where applicable, individual timing is provided by a third party contractor. Every effort is made to ensure that your time is recorded correctly however Bicycle SA and the contractor accept no responsibility for any failure of the timing system to record your time for any reason whatsoever. Occasionally it may be necessary to alter or amend itineraries, accommodation and other arrangements from those published. Bicycle SA strongly recommends all participants take out Personal Accident and Ambulance Insurance. I agree to abide by any directions given by event director, marshals, or any official event personnel. I consent to the publication of any photographs taken of me during this event. I consent to my contact details being added to any information mail out lists used by Bicycle SA in line with its privacy policies. I consent to my contact details being shared with the The Smith Family to facilitate limited communication specific to fundraising for this event and the creation of an optional fundraising page. I understand that events occasionally need to be cancelled and/or published information needs to change. In such circumstances, we will do our best to supply a comparable event. Cancellation of the event may occur if weather conditions prove to be too dangerous. If an event is cancelled information will be provided at the event and prior to the event on www.bikesa.asn.au or by phoning (08) 8168 9999. In the event Bicycle SA cancels the event, entry fees are transferable to other Bicycle SA events, but are not refundable. In the event I cancel my registration I accept the following fees will be levied: - Cancellation notified more than 30 days prior to event - no cancellation fee applies; - Cancellation notified 30 days or less and more than 14 days prior to event - a cancellation fee of 50% applies; - Cancellation notified 14 days or less prior to event - a cancellation fee of 100% applies