Variety Postie Bike Dash 2019 Registration FormPostie Dash 2019 Entry Form Step 1 of 333%Will this be your first Postie Bike Dash*YesNoWe’re so glad you are joining us on the Variety Postie Bike Dash 2019As we visit lots of wonderful schools along the Dash and want to ensure the safety of the kids you work so hard to support; we require all Dash entrants to have a valid Working With Children Check (WWCC). This is available free of charge for volunteers and can be applied for online here. Once your application is submitted you will then be required to take your application number to a Service NSW outlet who will then email your WWCC to you. When you have received your WWCC if you could please upload it below in order to complete your entry application. Also as a first time entrant we will also need a copy of your Drivers Licence which you can scan and attach below: If you have any issues with completing the above please contact Janet at the office on 02 4965 4911.We’re so glad you are joining us again on the Variety Postie Bike Dash.As you know we visit lots of wonderful schools along the Dash and want to ensure the safety of the kids we work so hard to support; we require all entrants to have a valid Working With Children’s Check (WWCC). This is available free of charge for volunteers and can be applied for online here. Once your application is submitted you will then be required to take your application number to a Service NSW outlet who will then email your WWCC to you. When you have received your WWCC if you could please upload it below in order to complete your entry application. If you have any issues with completing the above please contact Janet at the office on 02 4965 4911.Copy of Drivers Licence*Working With Children Check (WWCC)* Name* First Last Preferred NameBike Number (Please call the Newcastle Office on 4965 4911 to confirm your bike number if you haven’t done so already)*Bike Registration (All bikes entered must be a Honda CT110 or Honda NBC110 Super Cub)*Bike Year*Entry Classification*Individual EntryTeam EntryTeam NameGender*FemaleMaleDate of Birth*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Email* Phone*Are you entitled to a Dash Service Certificate?YesNo(Certificates are awarded for 5 years of service)Do you authorise Variety to provide your contact details to other Dash participants and/or the media?*YesNoDash Shirt Size*Mens SMens MMens LMens XLMens 2XLMens 3XLMens 4XLMens 5XLWomens 8Womens 10Womens 12Womens 14Womens 16Womens 18Do you require space in the baggage truck?*Yes PleaseNo ThanksEmergency Contact Details (someone not on the Dash)Emergency Contact Full Name*Relationship to you?*Mobile phone number*Medical InformationTo assist Dash medical personnel while on the event, please provide any relevant medical information we should be aware of. All information provided will remain confidential.Do you have any significant medical history? (If yes provide details)Do you currently take any prescribed medication? (If yes provide details)Do you have any major allergies? (If yes provide details)GP or Medical Centre name*GP or Medical Centre phone number*Please list any dietary requirements Indemnity and DisclaimerIn consideration of Variety - the Children’s Charity (NSW), hereinafter known as Variety, permitting the Participant to take part in the Event in any capacity, the Participant acknowledges that:1. the Event is a potentially hazardous event to those taking part and the Participant does so at his/her own risk;2. 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.3. 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:4. 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: a) Variety or; b) 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 Land owner 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;5. 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.6. 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.7. this Indemnity shall be governed by and construed in accordance with the law of New South Wales being the State of incorporation of Variety;8. the Participant will pay all entry fees and other charges imposed by Variety in respect of the Event;9. "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 (N S W) - 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 Postie Bike Dash you are a representative of Variety and hereby 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 ride 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 and/or 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 - the Children’s Charity’s aims, objectives and vision, and ensure at all times that my conduct will not negatively impact or denigrate Variety.• Abide by any decisions made by the Event Chairman or Motoring Events Manager regarding unacceptable behaviour by any participant and subsequent request to leave the event.Temporary Mechanical Repairs• I acknowledge that temporary repairs may be carried out on my bike during the course of the 2018 Variety Postie Bike Dash. I understand that these repairs will be carried out to the best of the ability of the mobile workshops.• I agree that these are considered temporary repairs only. Neither Variety - the Children’s Charity NSW, nor the mobile workshop crew involved takes any responsibility for the emergency repair.• It is my responsibility to have emergency repairs checked by a qualified mechanic at either the first town from where the repair took place or at the first reasonable opportunity.CONDITIONS OF ENTRY I agree to comply with the following conditions of entry for the Variety Postie Bike Dash 2019:•Acceptance of entries in the Variety Postie Dash is at the absolute discretion of the Committee and that acceptance of this application form does not guarantee a place on the Dash.•At least $2,000 in funds must be paid, either personally or through donations, to Variety, The Children’s Charity by 7 days prior to the start of the event. This including a $500 Non Refundable Entry Donation which must be received by 7th October 2019.• Provisions and any extra merchandise MUST be paid by 7 days prior to the start of the event.• Entry to the event is entirely at my own risk and that Variety Bike Postie Dash rules and regulations, as well as the rules of the road as prescribes by State laws and statues with be abided by during the event.• All bikes entered in the Dash must be roadworthy, registered & insured as prescribed by State laws.• Individual numbers to be visibly displayed (2 digit maximum) on the bike throughout the event.• All Bikes are required to attend the nominated Checkpoint Day prior to the start of the Dash. Any Bikes unable to attend the Checkpoint Day need to obtain prior consent from the Regional Motoring Events Manager. The bike must be presented in the form of a standard Honda CT110 Motorcycle or a standard Honda NBC110 Super Cub in every aspect including the rear rack, mudguards and engine crash plate and abide by the following conditions:• Rims are to be standard CT110, however your tyre selection is unrestricted as long as they fit the standard rims and clear the standard mudguards.• Front suspension may be improved provided all improvements are housed within the standard fork tubes and sliders.• Rear suspension may be improved but no modifications are to be made to mounting or shock travel.• Exhaust can be modified at will but not exceed legal decibel levels set by State laws.• Carburettor must be standard.• Air cleaner can be changed, however, please be aware the substitution for a more open system may leave the engine vulnerable to dust intake in most conditions we will be riding in.• Fuel to be standard pump fuel with a maximum octane of 98.• Engine horsepower must not exceed the manufacturers 7.6 H P (5 kW).• Transmission must be standard.• Drive sprockets can be changed.• Handlebars are to be standard or a similar bar style and any changes must meet Roads and Marine regulations.• No modification is allowable to brakes.• Must have a container the approximate size of a milk create mounted on the rear rack to display sponsors’ signage and carry a 5 litre fuel container with the appropriate fuel to suit your bike, drinking water and a basic first aid kit. As a rider, I agree to comply with the following conditions:• Am over 18 years of age.• Hold a current motorcycle licence (NO LEARNERS PERMITS).• Will wear an approved motorcycle helmet with some form of chin protection (NO OPEN FACE HELMETS) whilst riding.• Will wear closed in footwear, gloves, long trousers, protective jacket and fluro vest provided whilst riding.I agree to the above Indemnities and Disclaimers, Code of Conduct and Temporary Mechanical Repair Agreement for the Variety Postie Dash 2019* YesDonation DeclarationI pledge to raise a minimum of $2,000 in funds to Variety – the Children’s Charity prior to the start of the Postie Bike Dash including a non-refundable $500 entry donation.Payment of Entry Donation* Credit Card - Please enter your details below Direct Deposit - Direct Deposit - Name: Variety the Children’s Charity NSW – Gift Account BSB: 032 020 Account Number: 208569 Reference: NEWCDASH and your Bike Number eg. NEWCDASH-46) Cheque - Mail to PO Box 186 Broadmeadow NSW 2292 or hand deliver to the Newcastle Office 155-157 Lambton Road Broadmeadow NSW 2292 $500 Donation has already been remitted Everyday Hero - please follow the prompts to donate via your personal or team Everyday Hero pageCredit CardAmerican ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20192020202120222023202420252026202720282029203020312032203320342035203620372038 Expiration Date Security Code Cardholder Name Submit This iframe contains the logic required to handle Ajax powered Gravity Forms.