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The Big Rainbow Bike Ride Entry pack 2009

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The Big Rainbow Bike Ride Entry pack 2009 Powered By Docstoc
					  Albany
  Regional
  Hospital
                   THE BIG RAINBOW BIKE RIDE
           ALBANY – MT BARKER (via Porongurups) –DENMARK - ALBANY
                         One Open Ride Section Available
                          SATURDAY 24th October 2009
                              6.30 am for 7.00 am start
                      Ride starts and finishes at Lionetti’s IGA
                           Lower York Street, ALBANY
                                Maximum 100 riders


                                 Proceeds Will Benefit
                             Albany Regional Hospital and
                                  WA Police Legacy
                     ENTRY FORMS DUE NO LATER THAN 16/10/09
                 RAISE $150.00 in SPONSORSHIP FOR FREE ENTRY

Entry Fee:
$25 per rider
For more information call:                               DO ALL OR PART
Nigel Fiander or                9892 9300                OF THE RIDE
Shane Gregorini:
Keith Symes:                    9842 5900
Steve Maguire:                  9841 8097
Stuey Estcourt (Perth)          9222 1286

Entry Form with Fee
& Donor Form (with money)
To:    Sgt Nigel Fiander
       Albany Police
       Stirling Terrace
       ALBANY WA 6330


MAKE CHEQUES PAYABLE TO “WA POLICE LEGACY”
ENTRY FORMS AVAILABLE FROM :  Albany Police Station



                                              Albany Regional Hospital


                                              Great Southern Bicycle
                                              Company
 Albany
 Regional
 Hospital
                         THE BIG RAINBOW BIKE RIDE
                                ENTRY FORM
                                      CONDITIONS OF ENTRY

The declaration must be signed by all competitors. Entries will NOT be accepted unless
this declaration is signed
In consideration of, and as condition of acceptance of my entry, as a competitor in the Big
Rainbow Bike Ride (the Event) my signature appears hereunder, and I agree and declare as
follows: -

1.   My medical condition is satisfactory for the purpose of participating in the Event and any activity
     associated therewith and I am aware that the Event is comprised of arduous sessions in which only persons
     in good physical condition with suitable experience should participate.
2.   That I will abide by the rules and conditions of the Event as stated in this declaration and in any literature
     or instruction associated with the Event.
3.   That for myself, my heirs, executors and administrators I HEREBY WAIVE, all and any claim, right or
     cause of any action which heirs , executors or administrators might otherwise have arising out of my life or
     injury, damage or loss of any description whatsoever and however caused (including inter alia negligence
     of any person, corporation or body referred to in Section 4 below) which I may suffer in the course of or
     consequence upon or incidental to my entry or participation in the Event.
4.   The above waiver, release and discharge shall be and operate in favour of all persons, corporations and
     bodies involved or otherwise engaged in the promotion or staging the Event and the servants, agents,
     representatives, officer, any of them includes, but is not limited to, event organisers, their employees,
     agents, volunteers and marshals.
5.   That I consent to the publication of or use in any form whatsoever of my name, photograph, image, voice,
     statement or otherwise in any context pertaining to the Event or otherwise before, during or after the
     Event for advertisement, promotion or otherwise.

Signed:

Date:
    Albany
    Regional
    Hospital
                            THE BIG RAINBOW BIKE RIDE
                                   ENTRY FORM
                                      (must be filled out by each competitor)
                                             (Photocopy as necessary)

Name:
Address:

Telephone No:                                      E-mail Address:
Sex                           M/F                  DOB:

I want to do                                                                 (type X or tick in the relevant box/es)
1                  The whole ride

2                  Specified Part/s
                   2.1    Albany – Mt Barker (Via Porongorups)
                   2.2    Mt Barker – Denmark
                   2.3    Denmark - Albany

3                  A number of 10km legs with breaks on the bus myself/ as part
                   of a team

The ride starts at 7.00am from Lionetti’s IGA Supermarket, York Street, Albany

Do you a history of illness that may be aggravated by activity?                                   YES / NO
Please supply details:



Is there any other information that we should know about your health and safety, or for appropriate
action in the event of illness or injury (eg: asthma, epilepsy, diabetes)



                                                   Participants Consent
I hereby authorise the representatives of Western Australian Police Legacy (Inc.) to take actions (such as administer
first aid , evacuate, seek medical advice and/or treatment) as may be deemed necessary for my health and safety
I advise that I have read and understood the information as set out in this form.
Signed:
Date:
Emergency Contact:
Name:
Address:
Telephone:     Home:                     Work:                      Mobile
Entry forms must be returned with Entry fee of $25.00 by 16/10/2009
      To Sgt Nigel Fiander Albany Police Station, Stirling Terrace, ALBANY WA 6330
Albany
Regional    SPONSORSHIP FORM
Hospital
                 THE BIG RAINBOW BIKE RIDE
                       PROUDLY SUPPORTING
                       ALBANY REGIONAL HOSPITAL
                          & WA POLICE LEGACY

                    SATURDAY 24th OCTOBER 2009
                      RAISE $150 for FREE ENTRY
   NAME: _____________________________________________
ADDRESS: _____________________________________________PHONE: ___________

   Donors Name    Amount             Address               Signature

				
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