Contact: Tom Farrell
06
Apr
2019
Alexandra
VIC
Australia

Cycle Dindi 2019 - Registration Form

 

        

 

Name:

 

Address

 

Suburb/Town & Post Code

 

Mobile phone number

 

Email

 

Special  Dietary Needs

 

Emergency Contact

                                           Mob.

Please circle option

Options & Distances

Adult

Senior

Concession

Long Ride

Yea to Bonnie Doon            (return)    121 Km

Bonnie Doon to Yea            (return)    121 Km

Bonnie Doon to Cathkin     (return)     80  km         

$50

$40

$10

Short Ride

Yea-Cathkin                          (return)     42 Km

Yea- Yarck                             (return)      54 Km

Yarck –Yea                            (return)     54 Km

$40

$30

$10

 

 

 

 

 

 

 

 

 

 

 

 

 

Concession applies to school aged participants

Seniors:  Holders of Seniors’ cards

Under school age:  free.

Payment Details (Tick Box)

                  Credit/Debit card payment at trybooking.com   (cycledindi19)

                    

                  Direct Deposit to Bendigo Bank BSB 633-000 Account Number 161857420.

                 Account Title: - Cycle Dindi

Please reference payment with name and ride option.

Registration by post to PO Box 149 Yea 3717 or email entry to: cycledindi19@gmail.com

 

 

Release and Indemnity             Cycle Dindi 19

 

 

 

The Rotary Clubs of Yea, Alexandra & Mansfield   and Alexandra............................................................................................................................................ Inc. (“Rotary)

 

 

1.         I, .................................................................................... of .......................................................................................

..............................................................................in the State of ............................................ am aware and acknowledge that

Cycle Dindi 19............................................................involves inherent risks, including the risk of injury to life or death and damage to property and in undertaking such activities, I do so at my own risk.

 

2.         I     am     also     aware     that     it     is     a     condition     of     participation     in     .............................................................................

.Cycle Dindi 19............................................. that Rotary, its officers and employees, agents and volunteers are released by me from all liability howsoever arising from injury or damage to both property and person howsoever caused (whether fatal or otherwise) arising out of my participation in the Event whether or not such injury or damage is due to any negligent act, breach of duty, default and/or omission on the part of Rotary, its officers and employees, agents or volunteers.

 

3.         I indemnify Rotary, its officers and employees, agents and volunteers against all loss, damage and expenses (including legal costs on a solicitor and own client basis) arising out of or in connection with any claims, actions, proceedings or demands of any kind arising directly or indirectly as a consequence of my participation in the Event.

 

4.         I acknowledge and agree that my participation in the Event is as a consequence of my own free will and desire and that I have read and understood the above warning, release and indemnity.

 

5.         I warrant that I am 18 years of age or older and am lawfully able to enter into this above release and indemnity or, in the event that I am a minor, I have the permission of my legal guardian to participate in the Event and that my legal guardian has agreed to adhere to the terms of the indemnity below.

 

Signed……………………….............................................................................

 

Dated this                                        day of                                                                                                      2019

 

How did you hear about Cycle Dindi?

 

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