Mini Bash Entry FormStep 1 of 333%Car Number*If you haven’t been allocated a car number yet please call Janet Kilazoglou on 4965 4911 or email [email protected]First name*Last name*Preferred nameGender*FemaleMaleDate of Birth* Date Format: DD slash MM slash YYYY Address* Street Address Suburb Australian Capital TerritoryNorthern TerritoryNew South WalesQueenslandSouth AustraliaTasmaniaVictoriaWestern Australia State Postcode Email address* Contact Number*Will this be your first Mini Bash?*YesNoPlease list names of all other adults travelling in the vehicle*Do you have any kids that will be participating in the Mini Bash?*NoYesPlease list names and ages of all children participating: Emergency Contact DetailsEmergency Contact* First Last Relationship to you Contact Number*Indemnity and DisclaimerIn consideration of Variety - the Children’s Charity NSW/ACT, hereinafter known as Variety, permits the Participant to take part in the Event in any capacity, the Participant acknowledges that:• the Event is a potentially hazardous event to those taking part and the Participant does so at his/her own risk;• the Participant must take out and maintain a comprehensive motor vehicle insurance policy and/or a third party property damage insurance policy for the Participant’s vehicle including adequate cover for the Event, and the Participant must not do or suffer to be done anything which would enable an insurer to avoid or deny a claim under any such policy.• this Indemnity operates according to its terms and shall not be read down nor shall the Indemnity or Disclaimer be affected or altered in any manner, term or condition notwithstanding that the Participant may have been induced to participate in the Event by representations made by or on behalf of Variety:• the Participant shall not make any claim or demand against Variety or against any Landowner for any reason whatsoever including (but not limited to) any Claim or Demand howsoever arising as a result of any action, default, omission or negligence of Variety or; Any Landowner over whose property the Participant may travel whilst participating in the Event, or in relation to or arising out of the Event; and to the fullest extent permitted by law the Participant hereby indemnifies and shall keep indemnified Variety from all liabilities, Claims or Demands which but for this Indemnity the Participant may have against Variety or a Landowner and hereby indemnifies and shall keep indemnified Variety and each Landowner in respect of any Claim or Demand brought by (or on behalf of) the Participant against Variety or any Landowner;• the Participant hereby indemnifies and shall keep indemnified Variety and each Landowner from and against each and every Claim or Demand arising as a result of any action, default, omission, or negligence of the Participant brought by (or on behalf of) any Landowner or any third party whether or not the third party takes part in or is otherwise connected with the Event.• the Participant must comply with all laws in force for the time being and must indemnify and keep Variety indemnified against any Claim or Demand arising out of a breach or alleged breach of any law by a Participant.• this Indemnity shall be governed by and construed in accordance with the law of New South Wales being the State of incorporation of Variety;• the Participant will pay all entry fees and other charges imposed by Variety in respect of the Event;• "Claim or Demand" means any claim, demand, action, proceeding, judgement, order, fine, penalty, sentence, and award of damage or costs of any nature whatsoever;• "Participant" includes the legal or personal representatives of the Participant;• "Landowner" means and includes the owner, lessee or occupier of any land and any employee, agent or independent contractor of any such person;• “Variety" means and includes Variety - the Children’s Charity NSW/ACT - Tent 56 and each of its officers, members, employees, agents and independent contractors and any volunteer assisting it in connection with the Event.Code of ConductBy participating in the Variety Mini Bash you are a representative of Variety and agree to:• Act honestly and in good faith at all times in the interests of Variety and its stakeholders• Behave in a lawful manner complying with all State, Territory and Australian Law.• Ensure I do not drive under the influence of alcohol (in excess of the legal Blood Alcohol Limit) or any drugs.• I agree to advise my team members of any pre-existing medical conditions prior to the event in order for them to inform medical assistance should it be required.• Conduct myself in an environment free from discrimination and harassment.• Avoid conflicts of interests.• Treat all Entrants, Officials and Staff Members with dignity, trust and respect.• Recognise that it is solely the role of the Event Chairman, Event Manager and Officials to instruct Entrants.• Refrain from entering into any discussion or correspondence that could be construed as derogatory or libellous towards Variety, Entrants, Officials and Staff Members.• Enthusiastically support Variety's aims, objectives and vision, and ensure at all times that my conduct will not negatively impact or denigrate Variety.• Be courteous to other road users as the event puts Variety under the scrutiny of local authorities and residents.• Drive to the road conditions at hand, I am aware that road conditions can change quickly. I am also aware the Bash is not a race or a contest of speed of any kind• Notify an official should I leave the event for any reason. If I cannot find one, I will call one as soon as I have phone service (phone contacts in Bash Handbook). I am aware that you will go looking for us if not notified and if outside help is employed to do this I will be liable for any charges if this proved to be a false alarm.• Not upload any images of incidents or inappropriate behaviour to Social Media sites as these could be detrimental to the event.• Abide by any decisions made by the Bash Chairman or Event Manager regarding unacceptable behaviour by any participant and subsequent request to leave the event.Conditions of Entry1. All vehicles entered in the Mini Bash must be roadworthy, registered & insured as prescribed by State laws.2. All cars must also display the event sponsor’s decals, as supplied by the organisers.3. All entrants in the Mini Bash must have paid to Variety either personally or through donations the sum on the Entry Form prior to the start of the event.4. At all times entrants must abide by the rules of the road as prescribed by State laws & statues.5. Acceptance of entries in the 2019 Variety Mini Bash is at the absolute discretion of the Variety Event Management and that acceptance of this application form does not guarantee a place on the Mini Bash.I agree to the above Indemnities and Disclaimers, Code of Conduct and Conditions of Entry for the 2019 Mini Bash* Yes Bash Car DetailsVehicle Registration*Number of Crew in Car*Vehicle Make*Vehicle Model*Vehicle Year*Do you authorise Variety to provide your contact details to other Bash participants and the media?*YesNoDonation DeclarationEntrants must pay $100 per adult ($20 for kids 12-17 years, kids under 12 are free) in funds to Variety to be paid by September 16 2019Payment of Entry Donation*Please select a payment optionCredit Card - please call the office on 02 4965 4911 to make a paymentDirect Deposit - Variety the Children’s Charity NSW –Gift Account, BSB 032 020, Account Number: 208569 *please use MINIBASH19 & your car number and surname as reference eg. MINIBASH19 95 O'BrienCheque - By Mail: Variety PO Box 186 Broadmeadow NSW 2292 In Person: Variety Newcastle office at 155-157 Lambton Road Broadmeadow Submit This iframe contains the logic required to handle Ajax powered Gravity Forms.