eFormPostal

PedalFest 2012 Entry Form

Ride Fees	Advance	Late Entry	Sat Only	Sun Only
Adult	$35.00	$45.00	$25.00	$20.00
Under 18	$10.00	$15.00	$10.00	$10.00
Family Entry	$80.00	$100.00	$55.00	$50.00
Advance entry includes Free entry to Kids and Cobwebs Charity Ride

Please Circle your Entry Choice with Pen.
Use one Entry Form for each Person/Family!

Please read Conditions of Entry and sign form

(1)Surname:

Given Name:

(2)Surname:

Given Name:

Children to be included in Family Registration-full name and age of each child please.

(1)Name/Age:

(2)Name/Age:

(3)Name/Age:

(4)Name/Age:

Riders under 14yrs of age MUST be accompanied by a cycling adult on all rides.

Street

Town

Postcode

Ph:(H)

Ph:(Mob)

Email:

PedalFest Shirts
	Child T-Shirts	Not Available
	ADULT Polos	Not Available
Total PedalFest Ride Fees			$
Grand Total			$

All Cheques payable to Westpac Rescue Helicopter Dungog Support Group
Polo/T-shirts to be picked up at the Reception Desk by the Dungog Information Centre

CONDITIONS OF ENTRY - READ THESE NOW!

1.	Entries must be on this Registration Form or a copy of the same.
2.	Entries must be fully completed and duly signed by each rider or (if aged under 18) by the rider's parent or guardian.
3.	The PedalFest Organising Committee reserves the right to reject or cancel any entry at any time.
4.	All riders must comply with the instructions of the Police or identified officials at all times.
5.	All riders must at all times follow the approved route as set out by the PedalFest Organising Committee, and unless directed by Police or an identified official will not undertake any variation of the route at any time.
6.	All riders agree that their involvement in Dungog PedalFest is at their own risk.
7.	Riders under 14 years of age MUST be accompanied by a cycling adult.
8.	The PedalFest Organising Committee will not be responsible for any loss or damage, personal or otherwise, in any event
	Now read DECLARATION on next page

DECLARATION and WAIVER

I, the undersigned and any family members registered with me, acknowledge and agree that in consideration of and as a condition of acceptance of my/our entry in Dungog PedalFest 2012 ("PedalFest"), for myself/ourselves, my/our heirs, executors, and administrators, I/we hereby waive all and any claim, right or cause of action which I/we or they might otherwise have, arising out of my/our injury or loss of life, damage or loss of any description whatsoever which I/we may suffer or sustain in the course of or consequence upon my/our entry or participation in PedalFest.

I/we understand that participation in PedalFest involves cycling on public roads used by other traffic and am/are aware of the hazards involved. I attest that I and any family members registered with me am/are physically fit and that my/our bicycles will be in sound mechanical condition at all times during my/our participation in PedalFest.

While riding during PedalFest, I/we agree to: wear a Standards Approved cycling helmet; abide by the road rules; obey the directions of Police officers and identified officials; and ride with care for others on the road.

In my judgement I/we have, and any family members registered with me/us have, sufficient confidence and experience to safely participate in PedalFest.

This waiver, release and discharge operates separately in favour of all persons, corporations and bodies involved or otherwise engaged in promoting or staging PedalFest and the servants, agents, representatives and officers of any of them, and includes but is not limited to the Hunter Region SLSA Helicopter Rescue Service Limited, the PedalFest Organising Committee and any associated sponsor, any medical and paramedical practitioners and personnel, and the Police Service of New South Wales whether or not the loss, injury or damage is attributable to the act or neglect of any one or more of them.

I/we have read the Conditions of Entry and the Declaration and Waiver and I/we agree to conform to all elements of them.

NOTE: If a more than one adult is registering for PedalFest on this form, then each adult MUST sign the form separately.
If the proposed PedalFest participant is under 18 years old, then a parent or guardian MUST sign on their behalf.

EACH ADULT PARTICIPANT IS REQUIRED TO CONFIRM THAT THEY HAVE READ AND UNDERSTOOD THE CONDITIONS OF ENTRY AND THE DECLARATION AND WAIVER AND AGREE TO COMPLY WITH SAME BY SIGNING THE REGISTRATION FORM BELOW

ALL Adult Participants Signature(s)
(or signature(s) of Parent/Guardian(s) if PedalFest participant is under 18)

Adult One Signature	Adult Two Signature
_________________________	________________________
Adult One Printed Name	Adult Two Printed Name
_________________________	________________________

Mail the form with your cheque or money order (made out to Westpac Rescue Helicopter Dungog Support Group) PLUS a Stamped Self-Addressed Business Envelope to:

PEDALFEST REGISTRATIONS
c/o Westpac Helicopter Service
P.O. Box 230
New Lambton NSW 2305

OR: present it to the Registration Desk by the Dungog Information Centre at Pedalfest, 8.00 to 9.30am