<p> “A Project of the Portland Rotary Club Inc.”</p><p>Beats Cycle for Hope Entry Form – Single Rider</p><p>Name: ……………………………………………………………………...... </p><p>Contact No: ………...... ……...... …………… Age (on day of event): ...... eMail: ...... </p><p>Emergency Contact Name: ……………………………..…..… Emergency No: …....…....…………………</p><p>Do you require return transport from Bridgewater to Portland? YES NO</p><p>Conditions of Entry</p><p>1. Cyclists under 12 years of age must be accompanied by a parent or guardian to participate. 2. I, the undersigned, in consideration of and as a condition of the acceptance of my entry, do hereby for myself, my heirs, executors and administrators waive all claims or cause of action which I or they may otherwise have arising out of loss, damage or injury which I may sustain in the course of or arising out of my entry or participation in the event. 3. I attest and verify that I am physically fit and have trained for this event and that I agree to consult with my medical practitioner prior to the event if I am in any doubt as to my fitness and whether to participate; 4. I hereby consent to receive medical treatment which may be deemed advisable in the event of injury, accident and/or illness during the event; 5. I hereby acknowledge that I have sole responsibility for my personal possessions and athletic equipment during the event and its related activities. The event organising individuals, organisations or sponsors of the event or any of their agents or servants, shall have no liability for any loss or damage occurring to any items of clothing, bicycle or other personal effects of participants in relation to conducting this event; 6. I hereby permit free use of my name, image and performance in broadcasts, telecast and any form of media to help promote the event. 7. Riders must abide by Victorian Road Rules</p><p>Declaration I have read and understood the Conditions of Entry and hereby agree to all terms.</p><p>Participant Signature: …….………………………………...………… Date: dd / mmm / yyyy Parent or Legal Guardian must sign below if participant is under 18 years of age on event day. I verify that I am the Parent/Guardian of ………………………………………...... who will be ………. years of age on the day of the event, and that he/she has trained for the event.</p><p>Parent/Guardian Signature: ………………………………………….. Date: dd / mmm / yyyy</p><p>Put a smile on your face and hope in your heart “A Project of the Portland Rotary Club Inc.”</p><p>Please email completed forms to: [email protected]</p><p>Put a smile on your face and hope in your heart</p>