2018 Rodney Coast Challenge Individual Entry Form
Sunday 11th November 2018
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 4th November 2018 will be deemed to be late entries. Late entry fee $30.00

No refunds after 4th November 2018 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 28th October 2018
Your answer
Event T Shirt - please select size * *
*T Shirts are included in race packs for entries received before 28th October 2018
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
Never submit passwords through Google Forms.
This form was created inside of Bamberger Family.