Individual Registration for the 2012 Ballarat Spokes Cycle Classic

Please complete the below form to register.

Prices for entering the Ballarat Spokes Cycle Classic can be seen on this page:

Prefix:	Mr Mrs Miss Ms Prof Dr
First Name:	*
Last Name:	*
Date of Birth:	Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Year 1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 *
Gender:	Please Select Male Female *
Address:	*
Town/Suburb:	*
State:	Please Select ACT New South Wales Northern Territory Queensland South Australia Tasmania Victoria Western Australia *
Postcode:	*
Email Address:	*
Home Phone:	*
Work Phone:
Mobile Phone:
Please do not print my details in any publications in regards to the 2012 Ballarat Spokes Cycle Classic.
Emergency Contact Details
Emergency Contact:	*
Phone Number:	*
Ride Entry
Ride:	Please Select 1 - OAMPS Insurance Lake Wendouree Classic - 2.5 hours 2 - Sixtyone Design Classic - 60km 3 - 3BA Classic - 85 km 4 - Pipecon Classic - 100 km *
Registration type:	Please Select Individual corporate/business rate (includes jersey)Concession - student/healthcare card holders(does not include jersey)Individual (jersey not included)Child under 10 (does not include jersey)
Free Jersey Size: Click here for sizing chart	Please Select XS S M L XL 2XL 3XL None *
	Purchase an additional jersey ($40.00)
Purchased Jersey Size:	Please Select XS S M L XL 2XL 3XL None
How did you hear about the ride?	Please Select Amys Ride Bike Shop Family, Friends Social Media TV, Radio Other *
Did you ride in the Ballarat Cycle Classic last year? *	No Yes
Referral information If someone referred you to the Ballarat Cycle Classic, enter their name here.
Referred by:
Additional Donation to the Ballarat Cancer Research Centre If you wish to make a donation on top of your ride entry fee, please enter the amount below. If not, leave blank.
Additional donation:
Raffle ticket You can purchase raffle tickets for $2 each The Rotary Club of Ballarat South is a great supporter of the Ballarat Cancer Research Centre. Their annual raffle will be drawn at the 2012 Cycle Classic. Fantastic prizes are to be won including a brand new Holden Cruze - Click here for all prizes. The raffle will take place at 1.00pm at the Start / Finish line. Be sure to buy a ticket...
Number of raffle tickets:
Team Information
Are you riding in a team?	Yes         No *
If so, enter the team code:
Insurance We recommend that you take obtain personal accident insurance before taking part. This type of cover is available through membership of Bicycle Victoria. The waiver that you sign as a condition of entry does not cover participants for accidents caused by yourself or another rider. If you require an ambulance, please note that you will be charged for the transportation. If your registration is unpaid within 14 days, the registration data will be deleted.
I agree to the terms and conditions of registration