Registration Form

Cycle Around Australia2013

REGISTRATION FORM

Complete & email to cycleacrossoz@hotmail.com or post to Cycle Across Oz, 58 Mentone Parade, Mentone Melbourne 3194. 

A separate form is required for each person and please ensure all sections are completed.

Name:                                                               D.O.B.

Address: 

Postcode: 

Email: 

Phone No: (H):                                                  (W):

(Mob.): 

Emergency contact (Not on ride).

Name:

Phone: 

______________________________________________________________

Tick which Stage you wish to participate in, enclose $250 (per Stage) non- refundable deposit and return the form. 

One free jersey per rider.

Stage          Date                          Itinerary                          Days      $ with GST    Tick

1           Mar 23- April 24          Melb. To Cairns                   33                 2,860

2           April 29- May 27         Cairns to Darwin                  29                 2,640

2A        April 29- May 11         Cairns to Mt Isa                    13                 1,210

3           June 1- June 20            Darwin to Broome                20                 1,870

4           June 25- July 24           Broome to Perth                   30                  2,860

5           July 28- Sept. 2            Perth to Melb                        37                  2,970

5A        July 28- Aug 19           Perth to Pt Aug.                    21                  1,980

5B        Aug 19- Sept 2             Pt Aug to Melb.                    16                  1,540

All        Mar 23- Sept 2             Melb. To Melb                 6 months           13,200

                                                   2 free jerseys                                        - 20% = 10,560

• If riding 3 or 4 Stages please subtract 10% from the total cost.

Cycling Jersey   (Please indicate size below by circling)

Mens         XXXL     XXL     XL     L    M       S

Ladies       24     22     20     18     16     14     12     10     8

NB            Extra cycling jersey will cost $99.00

I enclose the non- refundable registration deposit of $______.00

Method of payment  Cheque/money order (payable to Collis Ivey)  Electronic bank transfer (Contact Cycle Across Oz for bank details)

All prices are in AUD. 

A deposit will secure your place in your elected ride/s. 

Total balance for each stage is due by Jan 31st, 2013.

Inclusive in price.

• Camping accommodation (see itinerary for up-graded accommodation).

• Some meals (refer to itinerary).  

• Morning & afternoon tea supplies. 

• Support vehicle with cooking facilities. 

• All gear carried in vehicle up to 15 kgs per rider. 

• One emergency bicycle. 

• Limited bicycle spares. 

• Bicycle repair tools.

You must supply.

• Most meals. 

• Bike and camping equipment (see suggested equipment list). 

• Bicycle spares (tube, tyre, cable, tube repair kit) 

• Adequate travel insurance. 

• Bicycle safety equipment. 

• If riders wish to upgrade accommodation then this is at their own expense.

I understand that the "Cycle Around Australia 2013" Ride is to be conducted on public roads in Australia and that "Cycle Across Oz" will not be responsible for any injuries, sickness or personal loss that may be incurred whilst I am participating on this ride.

Signature 

Date