South Bunbury Rotary Club : Register

Personal Details

First Name *

Last Name *

Email Address *

Password*

Mobile *

Dietary Requirements

Shirt Size *

By selecting this check box, you agree to be contacted by SBRC for the purposes of communicating event details, offers, newsletters and other information as required.

Yes No

Postal Address *

(enter manually)

Address Line 1 *

Address Line 2

Town/Suburb *

Postcode *

State *

Country *

Emergency Contact Details

Please provide us with an emergency contact

First Name *

Last Name *

Contact Number *

Relationship to you

Medical Conditions

Do you have any pre-existing medical conditions which might affect your ability to take part, or be relevant if treatment is needed?

Yes No

Terms & Conditions

Release and Indemnity 2023

The Rotary Club of South Bunbury Inc. (“Rotary”)

‘Dirt n Dust Run’

I am aware and acknowledge that Rotary Club South Bunbury Dirt n Dust Run involves inherent risks, including the risk of injury to life or death and damage to property and in undertaking such activities, I do so at my own risk.

This Agreement may not be affected or altered except by RCSB, or an RCSB authorised appointed representive.

In participating in the Event, the Participant acknowledges that they have not relied on any representation by RCSB.

This Agreement is subject to the Motor Vehicle (Third Party Insurance) Act 1943 as amended and the Civil Liability Act 2002 as amended.

This Agreement is to be construed as preserving any right or remedy any Participant may enjoy under the Motor Vehicle (Third Party Insurance) Act 1943 as amended.

This Agreement is governed by and construed in accordance with the laws of Western Australia.

By checking these Conditions of Entry, the Participant registered acknowledges ACCEPTANCE of all that is contained herein and covering any additional documentation that is required by RCSB, including without limitation any Official Entry Form, Medical Particulars Form, or any other Event documentation.

I agree to the above Terms & Conditions *

Additional Medical information

MEDICAL INFORMATION

It is extremely important that the Medical Information below, is completed prior to commencement of the event, no person will be permitted to participate unless this form has been submitted.

You must include details of any condition that has the potential to affect you on the event and any medications you are taking. Please include if you need to carry epi-pens, and where you keep them stored.

You must also inform and provide details of any changes to your medical condititon/s and any information that has changed or requires updating prior to the run.

The information is held in strictest confidence and only accessed in case of an emergency. The event practitioner may contact you if further information is required.

Please list current medication (you MUST carry sufficient supply of your medications to last past the duration of the event)

Please list any allergies (food / medications)

Returning Duster?

If you are new to the run, (lucky you, we have a great run planned for this year!)

Have you participated in a Dirt n Dust event previously? Select your level for this year.

NO- First Timer
My 2nd Run
My 3rd Run
My 4th Run
My 5th Run
Yes - I've been on every run

What name would you like to go by? Nickname? Team name? Enter Your Badge Name *

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You are registering as Team Captain

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Personal Details

Postal Address *

Emergency Contact Details

Medical Conditions

Terms & Conditions