Support Crew Registration 2022

First Name*

Last Name*

Email*

Address*

Date of birth*

Gender*

Male

Female

Other

Phone*

Emergency contact name*

Emergency contact number*

Support Type ($150)*

Driver

Support Crew

Current Drivers License*

Yes

Confident With A Trailer?*

Yes

Shirt Size*

Do you have any specific dietary requirements?*

Yes

If selected yes above please explain

Existing medical condition*

Yes

If selected yes above please explain

How will you pay the entry payment ($150)*

Cash

Online Banking (please check your email for acc number)

WAIVER RELEASE &; INDEMNIFICATION – In consideration of my entry in the 2021 Central South Island Charity Bike Ride, I have read and hereby agree to the 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 2021 Central South Island Charity Bike Ride. I have read and understand the Waiver Release and Indemnification and agree to the Conditions of Entry If the ride is postponed/cancelled for Covid related issues, the committee will refund/transfer an amount they feel fair to all parties.

Do you agree to the waiver and conditions of entry?*

Yes

Welcome back,