BROOME TO PERTH

www.cycleacrossoz.com.au

Tel. +61 03 95835414

Email: cycleacrossoz@hotmail.com

APPLICATION FORM

Name:______________________________________D.O.B.______________

Address:________________________________________________________

____________________________________________Postcode____________

Email:______________________________________

Phone No: (H):_______________________

(W):____________________

(Mob.):__________________

Broome to Perth- April 20th - May 18th 2011

Booking Conditions

Price: AUD$2350.00

AUD$250 non-refundable deposit required to secure a place on the tour.

Balance due January 31^st 2011.

Inclusive in price.

• Camping accommodation at caravan parks (see itinerary for up-graded accommodation).
• Some meals (refer to itinerary).
• Morning teas.
• Support vehicle with cooking facilities.
• All gear carried in vehicle.
• One emergency bicycle.
• Limited bicycle spares.
• Bicycle repair tools.

You must supply.

• Most meals (see brochure).
• Bike and camping equipment (see brochure).
• Bicycle spares (tube, tyre, cable, tube repair kit)
• Adequate travel insurance.
• Bicycle safety equipment.

I/we understand that the "Broome to Perth" Ride is to be conducted on public roads in Australia and that "Cycle Across Oz" will not be responsible for any injuries, sickness or personal loss that may be incurred whilst I/we are participating on this ride.

Signature___________________________________Date___________________

*(2^nd person-if applicable)

*Signature____________________________________Date___________________

MEDICAL INFORMATION FORM

(CONFIDENTIAL)

1. Do you have private health insurance? Yes No

Name of fund___________________ Contribution number__________________

2. Do you have Travel Insurance (Highly recommended)? Yes No

Name of Insurer_________________ Contribution number__________________

3. Do you have ambulance cover? Yes No

Inscriber number_________________

4. Medicare number___________________ Expiry date: ___/____
5. Emergency contact person and contact number (please supply 2 persons)

1^st contact_________________________________________

__________________________________________

2^nd contact_________________________________________

_________________________________________

6. Please list any relevant medical conditions.

__________________________________________

__________________________________________

__________________________________________

7. Do you suffer from the following conditions?

Heart disease Yes p No p

Diabetes Yes p No p

Epilepsy Yes p No p

Asthma Yes p No p

If Yes for any of the above, what is your current treatment prescribed:

__________________________________________

__________________________________________

__________________________________________

8. Please list any food or medication allergies:

__________________________________________

__________________________________________

__________________________________________

Name:_______________________ Signature___________________

Date____________________

WAIVER AND RELEASE OF LIABILITY AGREEMENT

Please read and sign this agreement:

In consideration of the acceptance of my application for the Cycle Across Oz trip, Broome to Perth, I, for myself, my heirs, executors, administrators, successors and assigns hereby release, waive and forever discharge Cycle Across Oz and all supporting bodies, associations, advertisers and sponsers and all of their respective agents, officials, volunteers, servants, contractors, representatives, successors and assigns of and from all claims, demands, damages, costs, expenses, actions and causes of actions, whether in law or equity, in respect of my participation on the Broome to Perth Ride.

I have read and understood the Safety Recommendations suggested by Cycle Across Oz and will adhere to them.

I acknowledge having read this Waiver Agreement, fully understood itÕs terms and sign freely and voluntarily without any inducement.

Name: ________________________ Signature_______________________

Witness (must be over 18 years of age):

Name:________________________ Signature________________________

Date:_________________________