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Vulcaniser 2011

Page One

1. Please enter your details

First Name *This question is required.

Last Name *This question is required.

Street Address *This question is required.

City *This question is required.

Post Code

Email Address

Phone Number

Mobile Phone

In the event of emergency, who would you like us to notify?

Name
Mobile Number
Relationship to you
Will they be at the event?

2. Please select your race category *This question is required.

3. Please select your age category *This question is required.

4. I can provide a marshal for the afternoon race

First Name

Last Name

Email Address if different from above

Phone Number if different from above

Mobile Phone if different from above

5. Please select the appropriate fee *This question is required.

6. PROMO CODE

7. How do you plan on paying? *This question is required.

8. If paying in to the bank account, what reference will you use?

9. Have you read and understood and will adhere to the conditions of entry? *This question is required.

10. I waive, release and discharge the organisers from any kind of liability for death, disability, personal injury, property damage, property theft and all other foreseeable risks, claims or actions of any kind (including negligence) resulting, directly or indirectly, my participation in this event.

WRITE YOUR NAME (or parent/guardian if under 18) IN THE BOX *This question is required.

11. Have you ridden the Vulcaniser before?

12. To help us determine the effectiveness of various advertising options, how did you hear about the event?

13. Cactus would love to tell you about their products.

Tick the box if you DON'T want your email address given to them.

14. Do you have any further comments?

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