Friday, 31 May 2013

TERENGGANU CENTURY RIDE INDIVIDUAL ON LINE ENTRANCE FORM
Name
Gender
 Male 
 Female 
Category
 Under 18 ( age 14 - 17 yrs) 
 Men Open ( age 18 - 35 yrs) 
 Men Veteran ( age 36 - 45 yrs) 
 Men Senior Veteran (46 yrs and above) 
 Women Open ( 18 yrs and above) 
IC No. / Passport No.
Nationality
Date of Birth
Age
Phone no. (Home)
Phone no. (Mobile)
Email Address
Address
Postcode
State
Country
Jersey Size
 XS  
 L 
 2XL 
 S 
 XL 
 3XL 
 M 

Emergency Contact Person :

Name
Phone no.
Relationship

WAIVER: I undersign, certify that the information on this form is correct and have signed here to signify that I am in agreement with this entry, and will compete in accordance rule and regulation of the TERENGGANU CENTURY RIDE 2013 (TCR).

I understand that the T.C.R. will be a strenuous event requiring special bicycle handling skills. Which requires bicycle helmets to be worn by all participants while operating bicycle and there is NO exception to this requirement.

I hereby agree that to participate in this event and voluntarily assume such risks in consideration of being permitted to participate in this event:

1) I release for myself, my heirs, and personal representatives, and the undersigned registrant under age 18 (minor). Pedal Explorer, and their respective, officers, volunteers, sponsors and staff (indemnities) from any claim, liability, demand, action, and cause of action whatsoever (collectively, “claim”) arising out of this event;

2) if registered as a minor, I (as a parent a guardian) agree to indemnify and hold harmless each indemnities against any claim for any lost;

3) consent to emergency medical treatment if I am injured;

4) shall obey traffic laws and practice safety in bicycling.

Entry Fees :

01/07/2013 - 15/08/2013 : RM100.00
16/08/2013 - 30/08/2013 : RM120

Closing Date : 30/08/2013

Please make all entrance fee payment to :
Zulkarnain Shah A. Rahman - MALAYAN BANKING BERHAD 1040 681 35152
and kindly fax over prove of payment to 603-8996 4597.


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