READY TO REGISTER FOR THE LAKE ST CLAIR BIKE RIDE? Fill in your details below Ride Registration – 14 September 2019 Lake Ride Registration Form 2019 Early bird Early Bird Entry! Enter before 14th AUGUST 2019 and SAVE!First Name*Surname*Personal DetailsStreet Address*Suburb*State*NSWACTVicQldTasSAWANTPostcode*Email* Phone*Club or Team Name (if applicable)Emergency Contact DetailsEmergency Contact Name*Emergency Contact Number*Medical conditions (if applicable)Route DistanceEntries made after 14th August 2019 is an extra $10 per entrantChoose ride distance*75km Ride : $55.00 : Start 8:30am48km Ride : $40.00 : Start 9:00am16km Ride : $20.00 : Start 9:30amT-Shirt $20.00T-ShirtNo T-ShirtXSSMLXLXXXLRide Jersey $60.00Ride JerseyNo JerseyXSSMLXLXXXLTo receive on the day, jersey orders MUST be in by Tuesday 8th August 2017. Limited sizes available - Get in quick!Conditions: All entrants must read and agree to this declarationPlease click to read the Terms and Conditions - click here (opens in new tab) and please check the box below if you accept them to ride.Agree to terms and conditions* I agree to the terms and conditions specified above Entrant age* Entrant will be 12 years or over on the day of the ride DonationSupport the fantastic work of Witmore Enterprises!Donation amount Donation Amount AUDHow did you hear about the ride?How did you hear about the ride?*Social MediaWord of mouthNewspaper/MagazineDigital NewspaperGooglePoster/Banner AdvertisingTotalTotal $ 0.00 Payment by Credit CardCredit Card MasterCardVisa Card Number Expiration Date Month010203040506070809101112 Year20192020202120222023202420252026202720282029203020312032203320342035203620372038 Security Code Cardholder Name EmailThis field is for validation purposes and should be left unchanged.
