Sydney to CAMberra 2012 - Registration Page

Thank you for your interest in registering for the Sydney 2 CAMberra 2012 event.

Please complete the webform below, which will lead you to our payment page in order to finalise your registration.

Thanks for your support!

First Name: *

Surname: *

Address: *

Suburb: *

State: *

Post Code: *

Home Phone: *

Mobile Number: *

Email: *

Date of Birth: *

Gender: *

Emergency Contact Name: *

Emergency Contact's Number: *

Affiliated Club: *

How did you hear about the ride?: *

Do you have any medical conditions?: *

Medical details (Provider/Number): *

Bike Category: *

Cycling Jersey Size: *

Please refer to the manufacturer's website for sizing details - http://www.champ-sys.com.au/custom/cycling/size-chart

Cycling Short Size:

This field is only required for Package 2 and Package 3. Please refer to the manufacturer's website for sizing details - http://www.champ-sys.com.au/custom/cycling/size-chart

Cycling Australia Insurance Cover?: *

Yes

All riders are required to have up to date Cycling Australia insurance cover. For participants without current cover, insurance will cost an additional $77 with Cycling Australia and will cover riders until 31st March 2013. Log onto http://www.cycling.org.au/?Page=44057&MenuID=Membership%2F20013%2F0%2F to complete your Silver Ride Membership cover.

Member Number: *

Registration Type: *

Please visit http://www.stillbirthfoundation.org.au/Sydney2CAMberra2012 for further details on each registration type.

Payment Method: *

PayPal

EFT (Electronic Funds Transfer)

Cash at pre-registration event

I agree that I have read and understood all the Terms and Conditions outlined: *

I Agree

Please read the Terms & Conditions at - http://www.stillbirthfoundation.org.au/S2CTsandCs

little feet taking big steps ... to reduce stillbirth

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Sydney to CAMberra 2012 - Registration Page