Beats Cycle for Hope Entry Form – Family / Group Riders

Rider 1 (Group Leader) Name: ...... Age (on day of event): ......

Contact No: ………...... eMail: ......

Emergency Contact Name: ……………………………..…..…Emergency No: …....…....…………………

Rider / Team Member Name / Age (on day of event)
2
3
4
5
6
7
8
9
10

How many in team require return transport from Bridgewater? 0 1 2 3 4 5 6 7 8 9 10

Conditions of Entry

  1. Cyclists under 12 years of age must be accompanied by a parent or guardian to participate.
  2. I, the undersigned, in consideration of and as a condition of the acceptance of my entry, do hereby for my group, heirs, executors and administrators waive all claims or cause of action which I or they may otherwise have arising out of loss, damage or injury which I may sustain in the course of or arising out of my entry or participation in the event.
  3. I attest and verify that the group members are physically fit and have trained for this event and that the group agree to consult with medical practitioners prior to the event if in any doubt as to fitness and whether to participate;
  4. The group members hereby consent to receive medical treatment which may be deemed advisable in the event of injury, accident and/or illness during the event;
  5. The group members hereby acknowledge that they have sole responsibility for personal possessions and athletic equipment during the event and its related activities. The event organising individuals, organisations or sponsors of the event or any of their agents or servants, shall have no liability for any loss or damage occurring to any items of clothing, bicycle or other personal effects of participants in relation to conducting this event;
  6. The group members hereby permit free use of group names, images and performances in broadcasts, telecast and any form of media to help promote the event.
  7. The group members agree to be bound by the ‘Conditions of Entry’ of this event;
  8. Group leader must be 18 years of age or over and must have explicit permission of parents or guardians of group members under 18 years of age.
  9. Riders must abide by Victorian Road Rules

Declaration

All participants in the group have read and understood the conditions of entry and agree to all terms.

Group Leader Signature: ……………………………………...………… Date: dd / mmm / yyyy

Please email completed forms to: