Registrations are now open for the "Central South Island Charity Bike Ride 2011"
By submitting this form you agree that:
You have read and understood the "Conditions of Entry" on THIS PAGE (click to view)
This registration form is for "Support Crew Only" If you wish to register as a rider please go HERE (click to go there)

---

Your Last Name

Your First Name

Date of Birth
eg: 16/07/1958
NB:Drivers must be over 25yrs of age

Address

Gender (select) Male Female

Email Address

Email Address (confirm)

Phone No (Home or Mobile)

Emergency Contact Name

Emergency Contact Number

---

Support Type & Cost
(Please select the appropriate type of entry) (select) Driver - $100 Support Crew - $100

I hold a current Drivers Licence
(You will be asked to produce your licence for inspection) (select) No Yes

I can tow and back a trailer
(Not a pre-requisite, but sure would be handy!) (select) No Yes

Diet
(Please state any specific Dietary requirements if any) None

Shirt Size (select) Small Medium Large XL XXL

Existing Medical Conditions
(Any medical conditions for which you are being treated that you wish the
organisers of the event to be aware of ? e.g. Asthma, Heart condition. etc. (select) Yes None

Detailed Medical Information
(If you answered yes to the above please supply details here.
All information will be treated with the utmost discretion) None

Entry Payment ($100.00)
(Please select how you will pay for your entry.
Your submission email will contain payment details )

Cheque Online Banking/Cash

Additional Meal Tickets
(Do you require additional meal tickets for the dinner on Saturday night.
E.g. partners, children etc. If yes please add $30.00pp to your entry payment) No Yes

Kurow Accommodation

Camping Ground Kurow Hotel (First 20) Waitaki Hotel (First 20) Kurow Motel
(Only for riders in the 15-20km group)

---

WAIVER RELEASE & INDEMNIFICATION In consideration of my entry in the 2011 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.

NOTE: 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. Persons under the age of 18 cannot submit this electronic form. Please submit a Postal Form from the Registration Menu above if you are under 18 and post to:

South Island Charity Bike Ride
P.O. Box 4007, Highfield, Timaru, 7942
Attention: CSICBR
Or scan & email to: bikeride@hospicesc.org.nz
(Entry will be subject to Committee approval)

I Have Read & Agree to the Rules & Conditions & the Waiver Release above (select) No Yes

  Submit Your Entry