Entrant Registration Form

 

JERSEYS TO WEAR ON THE DAY, ENTER AND ORDER ONLINE BEFORE 12 January 2010!
ENTRIES CLOSE 06 MARCH 2010
Donation to John Hunter Children’s Hospital:
$ (Get a free shirt with a donation of $60 or more!)
First Name:*
Surname:*
Male/Female:*
Age:*
Vegeterian Meal:*
Ride Distance:*
Train From:
Train To:
Shirts ($15):
Size     Quantity
Jersey ($90):
Size     Quantity
Select Entry Type:*

Contact Details

Email:*
Please provide a valid email address.
Phone:
Mobile Phone:
Mailing Street:*
Please provide your mailing address.
Suburb/City:*
Please provide your mailing address.
State:*
Postcode:*
Please provide the PostCode.
Please send a fundraiser kit/receipt book:
Extra Merchandise
 
Shirts ($15):
Size     Quantity
 
Jersey ($90):
Size     Quantity
 

By submitting this entry I indicate that I have read, understood &
accept the terms in the Conditions of Entry published on this website
 
Please contact 0407 206 981(Sandra) or entries@loopthelake.com.au if you have any problems

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