New Zealand Challenge 2019 - participant form
  1. Registration fees are as follows: - Australian cyclist AUD$1750 - New Zealand cyclist AUD$1450 (organise own transport to the event start) - Australian support crew AUD$1050 - New Zealand support crew AUD$750 (organise own transport to the event) Required payment dates: - Deposit: at time of registration $100 - 50% payment - August 1st 2019 - 100% payment - October 15th 2019 Payment adjustments: - discounts as per the event information page if applicable are offered as refunds on your full payment - you may elect not to include the supporters polo or hoodie in your fee if you already have the apparel from a recent event, please advise this is the case in your registration form - you may wish to purchase additional cyclist kits, tickets to send-off dinner etc, more will be communicated in regards to this after registration.
  2. Name(*)
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  3. Date of Birth(*)
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  4. Email address(*)
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  5. Phone number(*)
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  6. Address
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  7. Gender(*)

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  8. I am entering as(*)



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  9. Emergency Contact Name(*)
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  10. Emergency Contact Phone Number(*)
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  11. Cycling experience



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  12. Polo shirt requirements (support crew fee incldues 2 items, cyclist team incldues 1 item)(*)



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  13. Polo shirt size(*)






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  14. How did you hear about this event?
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  15. Please specify any dietary requirements
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  16. Please advise if you suffer from any of the following(*)











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  17. Details of medical conditions
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  18. Please advise if you have been hospitalised in the last two years

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  19. Are you suffering from or carrying an infectious disease

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  20. Are you registered as having a disability

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  21. Do you have skin wounds or ulcers

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  22. Do you have any sensory impairments

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  23. Do you have any ongoing medical problems

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  24. Further medical details
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  25. Details of any current medication
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  26. Year of last tetanus injection
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  27. Blood group
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  28. Do you object to blood transfusions

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  29. Details of private health insurance
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  30. Name and phone number of your private GP
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  31. Name and number of your private dentist
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  32. CHALLENGE FOR CHANGE 2019 MEDICAL RELEASE
    If emergency medical care is required for myself and if I, or an accompanying spouse or relative, am not able to convey permission in a timely manner, then I authorise appropriate emergency medical care as deemed necessary by emergency medical personnel, a physician or the medical facility providing treatment.
  33. I agree to the terms of the medical release(*)

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  34. CHALLENGE FOR CHANGE 2019 EVENT TERMS AND CONDITIONS
    The following are the terms and conditions of entry of Challenge for Change events (ABN: 17 133 069 002) held during 2019. These terms are not negotiable and by paying the entry fees for any Challenge for Change event, you are acknowledging that you accept the terms and conditions. For participants under the age of 18, a parent or guardian must accept. I agree to participate in this event on the following basis: 1. I release and indemnify all persons or corporations associated directly or indirectly with the conduct of the event from all liability, claims and costs whether in negligence or otherwise in connection with my participation in this event. This release shall extend to and include the organisers and project partners (event sponsors, event funding bodies, beneficiaries and their respective committee members, directors, employees, contractors, volunteers and representatives, the owners, licensees and occupiers of land and property upon which the event/s or any part of it is conducted including statutory bodies and local authorities). The indemnity includes an indemnity against any claims made for or on behalf of the participant who is a minor. 2. I understand that event may involve riding or walking on public roads used by other traffic in close proximity and I am aware of and accept the hazards involved. I understand that events may be held on public roads which will not be closed to traffic. 3. I agree (or have counselled the minor) to abide by the road rules of each state through which event may pass and to follow directions given by the organisers and police. 4. I accept that the event involves the real risk of serious injury or even death from causes including but not limited to; overexertion, equipment failure, dehydration, accidents with other event participants, spectators or road users, weather and other conditions. 5. I am over 18 years of age and of sufficient riding competence and fitness to take part in the event. My bicycle is in sound mechanical condition. (If the participant is a minor, then the parent/guardian signing this Deed consents to the minor’s participation and certifies that the minor is fit and capable of participating in the event. 6. I am (or the minor is) in good health and physically and mentally capable of completing the event. I acknowledge that if I am aware of an existing medical condition and uncertain of my state of fitness then a medical practitioner should verify my physical condition. I agree to advise the event organisers if I have a specific medical condition that may affect my own safety or the safety of others. 7. Safety precautions undertaken by the organisers (such as course supervision, race safety briefings, bicycle and helmet safety checks) are a service to me and other participants but are not a guarantee of safety. 8. I agree to (or shall direct the minor to) wear event identification and sponsorship materials as provided. 9. I acknowledge that private (the participant’s) support vehicles are not permitted along the bike route during the event/s. 10. I acknowledge that in registering for participation in the event, I may receive event information from Challenge for Change. I will read all the information pertaining to the event sent by the organisers including by hardcopy and email. As a parent/guardian, I agree to convey the information to the minor participant. 11. I acknowledge that film/video footage and still images may be taken by other participants, the organisers and official photographers and that these images may be used by the organisers and project partners for promotional and publicity purposes, operational assessments and related activities. I consent to the use of such images for these purposes. I acknowledge and consent to the event organisers providing my personal details (limited to participant number, full name and email address) to official photographers for the purpose of promoting photographs from the event. 12. I acknowledge that I am fully responsible for the security of my personal belongings, including my bicycle and other valuable items within the area that the event is conducted. The organisers and project partners will not be liable for replacement of any personal possessions. 13. If I wish to withdraw from the event, the following cancellation policy will apply: • Entry fees may be refunded up to four weeks prior to the commencement of the event minus administration costs only. • No refunds will be offered within four weeks prior of commencement of the event. 14. I acknowledge that I may receive a timing band at the event, which remains the property of the supplier that is recruited by the organisers. A recorded result is not guaranteed. Should I not return my timing band to the organisers, I agree to reimburse them the cost of the band. 15. Conduct, which in the opinion of the organisers has, may be or will result in a breach of these conditions, harm or damage to any participant or their property, illegal activity, bad language, or other unsocial behaviour, may result in removal from the event. 16. The organisers have the right to veto, edit or delete personal blog entries of participants that are deemed to have content that is defamatory, slanderous or otherwise offensive and which may bring the event, event organisers, project partners and/or other participants into disrepute. 17. The organisers reserve the right to refuse admission to the event to any person without providing a reason, even though that person may have been previously accepted as a participant in the event. 18. The organisers and project partners are not liable to the participant for any loss, damage, cost or expense of any kind if the participant is denied access to, or removed from the event for any reason. 19. The organisers reserve the right to change the accommodation, venues, the route, any information published about the event or items provided on the event without notice, and are not liable for any extra costs incurred by the participant as a result of these changes. 20. The organisers are not liable to the participant for any loss, damage, cost or expense of any kind due to program changes, poor weather before or during the event or postponement or cancellation of all or part of the event due to circumstances beyond the control of the organisers including, but not limited to; weather, safety, theft, disaster, accident, strike or direction by any government authority. 21. The participant is responsible for any damage and/or costs incurred to the organiser’s equipment that has been loaned and/or any spare parts given to the participant during the event. 22. If the participant is under 18 years of age (the minor) these terms and conditions must be signed by the legal guardian or parent of the minor who, by signing these terms and conditions, warrants that he or she holds that position and the indemnity and that terms and conditions contained in this Deed apply to any claim made by or on behalf of the minor. 23. By entering the event, the participant agrees to be bound by these conditions.
  35. I accept the Terms and Conditions(*)

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