The Rotary Club of Yea Inc.

 


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Cycle Dindi 2017  - Individual Registration Form

  

 

 

 

                                                  
Name:  
Address  
Suburb/Town and Post Code  
Mobile phone number  
Email  
Special Dietary Needs  
Emergency Contact Name and

Mobile Phone Number

 
Distance Adult Tick *Concession Tick
Yea/Alex – Molesworth return

33/35 kms

$40   $20  
Yea- Alex return

Alex-Yea return

68 kms.

$50   $20  


*Concession applies to school aged participants

Payment Details (Tick Box)

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

Direct Deposit to Bendigo Bank BSB 633-000 Account Number 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, I am agreeing to the conditions of entry.

Signature: ________________________________                       Date: _________________