Crowne2Crowne Cycle Classic Sunday 28 October 2012 Registration Form

Name: _____________________________________________________________
Address: _____________________________________________________________
Suburb: __________________________ Postcode: __________________________
Phone Numbers Work: ___________________ Home: _________________________
Mobile: _________________
Email: _____________________________________________________________

Yes, I wish to participate as a rider
Yes, I would like to be a volunteer
I would be interested in riding from Newcastle to the Hunter Valley to double the distance of the ride
Medicare No: _____________________________________________________________
Health Fund: _____________________________________________________________
Ambulance Cover: Yes / No
Next of Kin: _________________________
Phone: _____________________________
Signed: _________________________ Date: _______________________________

Please return completed form & registration fee of $50 per rider by 1st October 2012 to:
Kathy York

c/Crowne Plaza Newcastle

PO Box 411

Newcastle NSW 2300

Kathy.York@ihg.com

Note: by agreeing to participate as a rider you are committed to help fundraise for the
Westpac Rescue Helicopter Service.

Crowne2crowne Cycle Classic is authorized to raise funds on behalf of the
Westpac Rescue Helicopter Service.

 

ABN 40 002 862 026

www.rescuehelicopter.com.au

 

 

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