The Rotary Club of Yea Inc.

 


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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)

 

Address

 

Suburb/Town & Post Code

 

Mobile phone number

 

Email

 

Special  Dietary Needs

 

Emergency Contact Name and

Mobile Phone Number

 

 

Distance Family Tick
Yea/Alex- Molesworth & return

33/35 kms

$100  
Yea-Alex return

Alex-Yea return

68 kms

$125


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: cycledindi@gmail.com

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: _________________