Gisborne Rotary Club
Manual Entry Form
ENTRY FORM
Click here to print PDF attachment
YES please enter me/us in the ride...
Number of riders _______________
Registration fee $75.00 per rider. Starts 8:00am at
New Gisborne and takes in Woodend, Trentham,
Daylesford, Kyneton, Mt Macedon to finish at New
Gisborne. Includes map, power bars, water, sun
screen, first aid & BBQ meal at end of event.
Name(s) _______________
Address for mail _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Postcode _ _ _ _ _
Ph _ _ _ _ _ _ _ _ _ Fax _ _ _ _ _ _ _ _ _
Email _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Emergency Contact _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Emergency Contact Ph No _ _ _ _ _ _ _ _ _ _ _ _
Credit card payment
Mastercard [ ] or Visa [ ] Only
Card number _ _ _ _ / _ _ _ _ / _ _ _ _ / _ _ _ _
Card holder's name _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Expiry date _ _ / _ _ Amount $ ____________
I authorise the Rotary Club of Gisborne to debit my
credit card with the amount shown above. I certify
that I am over 18 years of age.
Card holder's signature _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Fax to: (03) 5428 3519
Or
Cheque payable to Rotary Club of Gisborne and
crossed Not Negotiable.
Mail to:
Rotary Club of Gisborne Inc
PO Box 292, Gisborne, Vic 3437
Inquiries: tel. (03) 5428 3474
email: patbial@bigpond