Registration forms can be posted or emailed to firstname.lastname@example.org
Your name: ____________________________________________ Male □ Female □
Partners name: _________________________________________ Male □ Female □
Email address: ___________________________________________________________
Phone (home): _______________________Phone (work): _______________________Phone (mobile): __________________________________
Emergency Contact Name: ___________________________________________Emergency Contact Phone Number: __________________________
Special Dietary requirements: ____________________________________________________________________________________________
Other (eg Medical info): ________________________________________________________________________________________________
I / We will be bringing a: Roadie □ Mountain Bike □ Non Rider □
□ $100.00 DEPOSIT per person on registration, with balance paid by 14th April 2017
□ Pay in full $430.00 per person on registration
□ Linen hire @ $22.00 per bed
□ By cheque made out to ‘Laurel Hill Forest Lodge’ Post to 1670 Batlow Road Tumbarumba 2653
□ By direct deposit Bendigo Bank Details: Laurel Hill Forest Lodge BSB 633 000 Account No.156987844 Please include your surname when making a direct deposit.
I understand that bicycle riding carries some degree of risk and I hereby accept all responsibility for my actions. I have enough ability and experience to participate safely in this event.
If under 18 must be signed by a parent or guardian.
Signature _______________________________________ Date__________ Signature _______________________________________ Date __________
If you are emailing this form back, the form can be signed on the 14th April 2017 when you arrive at Laurel Hill Forest Lodge.