Complete this form to register as a Road Rider, Dirty Boy, Pack Leader, Supporter or Child (non-rider)!

 
  • Main registration
  • Medical Details
  • Catering Requirements
  • Select your registration
  • Other important Information

Tell us who you are

What shall we call you?
Enter your last name
Thanks for clearing that up...
Just in case we want to turn up to your Birthday Party.
Just so we don't have to work it out.
Need to know where to turn up for that Birthday Party!
We'll try to call first... maybe
We can always try to call this one instead.... nahhhh
Tell us who and how to contact someone in case of an emergency.
Tell us your doc's name and phone number
Enter your medicare number
Indicate if you have private medical insurance
Indicate if you have allergies
Enter any allergies you have
Indicate if you carry an epipen
Indicate any medical concerns you may have
Enter any medical concerns you may have
Indicate if you have had any recent surgery
Enter any surgery you have had
Indicate when your last tetanus shot
Our Road Kill Catering Crew will cater for your requirements, tell us what you can not have.
If you have answered Yes above, tell us what food you are allergic to.
We need to let our Road Kill Catering Crew know of all dietary requirements.
Indicate your registration
How are you participating ?
Are you fast or do you like to take in the scenery ?
Are you fast or do you like to take in the scenery ?
Enter your Team's name
Indicate your jersey type
Indicate the jersey style
Indicate the size
Indicate the style
Indicate the size
Indicate the size

Jersey Size chart or Polo Size chart

Indicate if you want a Gulflander train ticket
Indicate if you want a return bus ticket
Indicate what you want for breakfast

Cancellation Policy

If you register and are unable to attend the ride you have the following options:

a) Transfer your registration to the next year
b) Transfer your registration to a friend
c) Receive a 50% refund if made more than 30 days prior to the event.

No refund is provided for cancellation made less than 30 days from the event start date.

If you are paying a deposit only.

Your deposit is non-refundable. The full amount of your registration must be paid by no later than 30 days prior to the ride.  (31 May 2019). Payments should be made directly into the charity's bank account, using your unique token number below as reference. Bank details below:

Milboe Ltd, Bendigo Bank | BSB 633 000 | Account 136 988 722

Failure to pay your balance on time will result in you registration being cancelled.

Indicate if you have read the cancellation policy

I understand that participating in this event is potentially hazardous, and that I should not enter and participate unless I am medically able and properly trained.
I take sole responsibility for my bike and any equipment I take with me to the event.
I take sole responsibility in loading, unloading my bike on and off any trailers and storing my bike.
I understand that I must fundraise the required amount stipulated in the Registration Fees section in order to participate in the event.
In consideration of the acceptance of this entry, I assume full and complete responsibility for any injury or accident which may occur while I am traveling to or from the event, during the event, or while I am on the premises of the event.

I am aware of and assume all risks associated with participating in this event, including but not limited to falls, contact with other participants, effect of weather and spectators. I, for myself and my heirs and executors, hereby waive, release and forever discharge the event organizers, sponsors, promoters and each of their agents, representatives, successors and assigns, and all other persons associated with the event, for all my liabilities, claims, actions, or damages that I may have against them arising out of or in any way connected with my participation in this event.

I understand that this waiver includes any claims, whether caused by negligence, the action or inaction of any of the above parties, or otherwise.

I hereby grant full permission to any and all of the above parties to use any photographs, videotapes, motion pictures, website images, recordings or any other record of this event.

Indicate if you have read and agree to the terms and conditions