The Rotary Club of Yea Inc.



Invitation to Enter

Print Family Registration Form

Single Entry

Cycle Dindi 2017  - Family Registration Form






Cycle Dindi 2017 - Family Registration Form


Family Surname


Individual adults


Individual children (school age)




Suburb/Town & Post Code


Mobile phone number




Special  Dietary Needs


Emergency Contact Name and

Mobile Phone Number



Distance Family Tick
Yea/Alex- Molesworth & return

33/35 kms

Yea-Alex return

Alex-Yea return

68 kms


Payment Details (Tick Box)

Cheque (Payable to the Rotary Club of Yea) or money order

Direct deposit to Bendigo Bank BSB 633-000 Account No. 144545126

(RC of Yea Inc.) Please reference payment with name and ‘Cycle Dindi’.


Send cheque or money order and registration by post to PO Box 149 Yea 3717 or email entry to:

Disclaimer: the participant (signed below) agrees that the Rotary Clubs of Alexandra and Yea will be neither liable or legally responsible for * any injuries sustained by the participant or * any loss or damage to property owned by, or in the possession of the participant.

By signing this form, we are agreeing to the conditions of entry.

Signature: _______________________________                                          Date: _________________