4-day Rider Registration

Name*

First Last

Date of Birth*

Company

Occupation

Mobile No*

Alternate contact no

Email*

Postal Address

Address*

Street Address Address Line 2 City State Postcode

License details

License no.

Date

Class

Medical details

Please list below any medical conditions, injuries and/or allergies:

Please list any dietary requirements:

Medicare

Health Insurance

Membership No.

In case of emergency, contact information.

Name*

First Last

Mobile*

Alternate contact no.

GP Contact details

General Practitioner

Contact No.

Do you have any first aid or medical training?*

If Yes, please specify training type:

Route & Deposit details

4 Day Participation = $1,600
Raise a minimum of $4,000 and/or support fundraising events
Includes: accomodation,bike & luggage transportation, food, airfare, 2x jersey & shorts, wind vest, arm warmers and socks, casual T-Shirt and a 3-month premium exercise science-based training package with Exercise Institute.

Options for partners *

1 night's accommodation, evening meal and breakfast the following morning
$150.00 per person /per night

* Subject to availability ** Price may be subject to change.

Full course

Price: $ 1,600.00

Additional accommodation

$150.00 per person/per night

Additional accomodation: $150 per person/per night

York
Narrogin
Bunbury
No selection

Total payable

$ 0.00

Payment Details

CHEQUE

Enclosed is my cheque or money order payable to Red Sky Ride

DIRECT DEPOSIT

Attached is a copy of my bank receipt for a direct deposit to: Bank: Westpac
Account Name: Red Sky Ride
BSB 036-304
Account 233 174

Upload bank receipt

This can be emailed later to michelle@solariscancercare.org.au

CREDIT CARD

Name on card

Credit or debit card no.

Expiry date

CVV

PAYPAL

Pay via PayPal

Read Terms & Conditions here.