Rider Online Registration

Rider Registration Form

Rider Online Registrations closed on the 30th Nov. 2011
You may still complete a registration form and your details will be saved and placed on a waiting list. If there are any spare places once all existing entries have been collated we will contact you.

To check your submission was successful you can check this page which updates every time a form is submitted. NB: This page only registers Online Submissions - Postal Submissions will not appear here

Please Note: Your entry will not be confirmed until your registration fee has been received.

Online Registration Form (Riders Only)

By submitting the form below you agree that:
You have read and understood the "Conditions of Entry" on THIS PAGE (Click to view)
Last Name(*)

Last Name required!
First Name(*)

First Name required!
Address(*)

Address required!
Date of Birth(*)

Date of Birth required!

(eg. 12/09/1965)
Gender(*)

Gender is required!
Email Address(*)

Invalid email address!
Confirm Email(*)

Invalid email address!
Phone No.(*)

Phone number required!
Mobile No.(*)

Phone number required!
Emergency Contact Name(*)

Contacts name?
Emergency Contact Phone(*)

Contact's number?
Ride Group(*)

Ride group required!
Shirt Size(*)

Shirt is required!
Existing Medical Conditions

(*)

Any medical conditions!
(Medical conditions for which you are being treated) Asthma, Heart condition etc.
Detailed Medical Information

Invalid Input
(If you answered yes to the above please supply details here. All information will be treated with the utmost discretion)
Entry Payment - $200(*)

Payment method!
Additional Meal Tickets(*)

Additional meals?

(Extra Meal tickets for Saturday night's dinner can be purchased for $35ea)
Kurow Accommodation(*)

Accommodation?
WAIVER RELEASE & INDEMNIFICATION
In consideration of my entry in the 2012 Central South Island Charity Bike Ride, I have read and hereby agree to the Rules and Conditions of Entry. I hereby release, exempt and indemnify the organizers, sponsors and other persons and organizations involved from all action, proceeding, demands and costs, expenses and claims whatsoever made or taken by any person arising out of my participation in the 2011 Trust Aoraki Central South Island Charity Bike Ride.
NB: Persons under the age of 18 cannot submit this online form.
A parent or guardian is required sign an entry for anyone under the age of 18.
Please complete a Postal Form from the Registration Menu above if you are under 18.
I agree with Waiver(*)

Acceptance is required!
Please help us to target our advertising by letting us know how you found out about the Charity Bike Ride.
Choose an Option(*)

Please choose an option

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