2017 Rodney Coast Challenge Individual Entry Form
Sunday 5th November 2017
Entry category
First name
Your answer
Family name
Your answer
Postal address
Your answer
Post code
Your answer
Phone
Your answer
Email
Your answer
Are you representing a School ?
Youth Category only - please type school name
Your answer
Payment Details
Please pay by direct debit to: 12-3139-0048950-01. Please enter family name as reference

Entries with a postal date after 30th October will be deemed to be late entries. Late entry fee $30.00

No refunds after 30th October without medical certificate

Entry fee - includes race t-shirt *
$90 for individual entry. For youth category, $75 per individual entry (13 - 18 years old) *T Shirts are included in race packs for entries received before 23rd October 2017
Your answer
Event T Shirt - please select size *
*T Shirts are included in race packs for entries received before 23rd October 2017
Donation
Any donations to the Kaukapakapa Scout Group are gratefully recieved.
Your answer
Total paid
Please add up entry fee, and donation amount if applicable
Your answer
Payment Reference or Cheque Number
If paying by direct debit please enter your family name as reference , or if sending a cheque please enter the cheque number
Your answer
Waiver
On behalf of myself and/or fellow team members, I/We accept full responsibility and /or liability for any damage to myself, equipment, fellow team members and/or third parties resultant from my/our participating in the Rodney Coast Challenge event and I/We waiver all or any claims against the race organisers and/or their staff. I/We also acknowledge I/We understand that at no stage are any roads closed to the General Public and I/We must at all times obey road rules in relation to cyclists or pedestrians. I/We also acknowledge that a charge of $30 will be made for any unreturned or lost race bibs and/or transponders
Signed
Your full name here
Your answer
Submit
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