The Rotary Club of Yea Inc.



Invitation to Enter

Print Individual Entry Form

Family Entry


Cycle Dindi 2017  - Individual Registration Form





Suburb/Town and Post Code  
Mobile phone number  
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:

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: _________________