Rotary Spring Cycle
Application form
Name:
Street address:
Suburb/City:
State: Postcode
Sex:
Work Phone Home Phone
Emergency contact - Name & phone number
Mobile
Email

Names & ages of riders,
event entered

Child (< 12 yrs) No charge
Youth (12-17 yrs) $20.00 x = $
Adult (18 yrs +) $25.00 x = $
Family (same address) $35.00 x = $
Team of 5 or more $20.00 x = $
Total entry fee
$
Payment: Please debit my credit card for $
Card Type
Card number Expiry date
Name on card

All entrants must accept the following declaration:

I understand that participation in the Rotary Spring Cycle involves cycling on public roads used by other traffic and I am aware of the hazards involved. In my judgement I, my child and/or members of my group have sufficent confidence and experience to safely participate in the event. I hereby release, exempt and indemnify the organisers of the Rotary Spring Cycle, the sponsors and all other persons involved in the organisation and running of the event. I agree to waive any claim, right or course of action which I, my child or members of my group or team, or any other person might have arising from death or personal injury, damage to property or any other loss, whether due to any negligence or omission on the part of those organising or running the event that may by suffered in the course of or consequent upon entry or participation in the event.
In order to participate in the event, all riders must agree to the above declaration. If an entrant is under 18 years, a parent or guardian must act on their behalf. By submitting this form, I agreed to the declaration.

Name:
Relationship (self, parent, guardian):
To send the form to Rotary Spring Cycle for processing, press the Submit button
If you have made an error and wish to start over, press the reset button