Main registration (draft)

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

RM_Stats

Main registration

Tell us who you are

Email^*

First name^*

What shall we call you?

Last name^*

Enter your last name

Gender^*

Male
Female

Thanks for clearing that up...

Date of Birth^*

Just in case we want to turn up to your Birthday Party.

Age^*

Just so we don't have to work it out.

Address

Need to know where to turn up for that Birthday Party!

Mobile number^*

We'll try to call first... maybe

Phone number

We can always try to call this one instead.... nahhhh

Medical Details

Emergency contact^*

Tell us who and how to contact someone in case of an emergency.

Medical contact

Tell us your doc's name and phone number

Medicare number

Enter your medicare number

Do you have private medical insurance ?^*

Indicate if you have private medical insurance

Do you have allergies ?^*

Indicate if you have allergies

If Yes, tell us what you are allergic to

Enter any allergies you have

Do you carry an epipen ?^*

Indicate if you carry an epipen

Do you have any medical concerns you feel we should know about ?^*

Indicate any medical concerns you may have

If Yes tell us

Enter any medical concerns you may have

Have you recently had any kind of surgery ?^*

Indicate if you have had any recent surgery

If Yes, what surgery have you had ?

Enter any surgery you have had

When was your last tetanus booster ?^*

Less than 1 year
1 to 2 years
More than 2 years ago

Indicate when your last tetanus shot

Catering Requirements

Do you have any food allergies^*

Our Road Kill Catering Crew will cater for your requirements, tell us what you can not have.

What are you allergic to?

If you have answered Yes above, tell us what food you are allergic to.

Do you have any dietary requirements^*

Tell us about your dietary requirements.

We need to let our Road Kill Catering Crew know of all dietary requirements.

Select your registration

Select your registration^*

Indicate your registration

We need to make sure you have selected the right thing.. riding ? not riding ? Pack leader or are you a supporter^*

Road rider ?
Dirty rider ?
Pack leader ?
Non rider ?
Supporter ?

How are you participating ?

Road pack type^*

Are you fast or do you like to take in the scenery ?

Dirty pack type^*

Are you fast or do you like to take in the scenery ?

If you are riding, are you part of a Team ? If yes let us know your Team's name

Enter your Team's name

Jersey type^*

Short Sleeve
Long Sleeve

Indicate your jersey type

Jersey style^*

Male
Female

Indicate the jersey style

Jersey size^*

Indicate the size

Knicks style^*

Male
Female

Indicate the style

Knicks size^*

Indicate the size

Polo size (unisex)^*

Indicate the size

Jersey Size chart or Polo Size chart

Other important Information

Would you like to purchase a Gulflander train ticket ?

Yes ($ 20)
×

Indicate if you want a Gulflander train ticket

Do you need a return bus ticket ?

Yes ($ 110)

Indicate if you want a return bus ticket

Do you need Breakfast at Normanton on the way back ?

Bacon & Egg Roll (GF Bread) ($ 10.00)
×
Toasted Sandwich (Ham & Cheese) (GF Bread) ($ 7.00)
×
Toasted Sandwich (Ham, Cheese & Tomato) (GF Bread) ($ 7.00)
×
Salad Roll (GF Bread) ($ 8.00)
×
Salad Sandwich (GF Bread) ($ 8.00)
×
Fresh Fruit Salad ($ 7.50)
×

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.

I have read and understand the cancellation policy.^*

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.

I have read and understand the Terms and Conditions^*

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

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Main registration (draft)

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

Cancellation Policy

If you are paying a deposit only.

Thanks for your donation

Donate

Setup your fundraising page

Gallery

More Information

7 DAY SNAPSHOT

Main registration (draft)

Main registration (draft)

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

Cancellation Policy

If you are paying a deposit only.

Thanks for your donation

Donate

Setup your fundraising page

Gallery

More Information

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7 DAY SNAPSHOT

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