Scenic Cycle Challenge 2015
Personal Details
Surname ______
Forename ______
Address______
Tel (mobile) ______
Email ______
Accommodation
Supplementary cost, if required. Please circle.
Room Type: Double (€65) / Twin (€65) / Single (€90)
Date: Saturday 11th April ____ Sunday 12th April _____
Next of Kin
Name ______
Relationship ______
Email ______
Tel (mobile) ______
Additional information
What jersey size do you require?
Small / Medium / Large / Extra Large ______
How did you hear about the cycle? ______
Are you happy to have your contact details shared with other Orbis Ireland cyclists? Yes / No
Are you happy to be placed on the Orbis Ireland mailing list? Yes / No
Registered in Ireland, charity number 16838 and a company limited by guarantee number 411144. Registered office: Bracken Court, Bracken Road, Sandyford, Dublin 18.
Terms & Conditions
1. Enclose a registration fee of €75 (€50 before 20th February 2015)
2. Undertake to raise a minimum of €300 for Orbis Ireland.
3. You are responsible for your own travel to and from Kerry.
4. You participate at your own risk.
5. If you have a medical condition that could affect your ability to take part in this event, you must provide written permission from your doctor. All disclosures will be dealt with in strictest confidence.
6. Orbis Ireland reserves the right to cancel the event if there are fewer than the minimum required number of participants.
7. In accordance with Cycling Ireland’s Technical Regulations you will ensure that your bicycle is in proper working order and that you wear a hard-shell helmet.
8. Follow the Road Safety Authority’s Rules of the Road and obey the instructions of event marshalls
DECLARATION
I apply to take part in the Scenic Challenge Cycle with Orbis Ireland. I will abide by the above terms and conditions. I confirm that to the best of my knowledge, my general state of health and fitness is good and I take full responsibility for my fitness to take part. I also accept responsibility for my actions and safety on the Scenic Cycle Challenge. In acknowledging and accepting these terms and conditions, I confirm to have an understanding of the level of risk involved in the event.
Signature______Print Name ______Date______
Payment details
I enclose my €75/€50 registration fee 0 (Please tick as appropriate)
I require a single room and enclose the €90 supplement 0 €180 supplement 0 (Please tick as appropriate)
I require a double/twin room and enclose the €65 supplement 0 €130 supplement 0 (Please tick as appropriate)
I enclose a cheque for €______(payable to ORBIS Ireland) or charge €______to my Visa / MasterCard / Laser
Card number ______Exp date ___ / ___
Name on card ______
Registered in Ireland, charity number 16838 and a company limited by guarantee number 411144. Registered office: Bracken Court, Bracken Road, Sandyford, Dublin 18.