Individual Participant Application Form	Vers 3/6/12

Thank you. By supporting us you help support literacy and education in Samoa. The Voice is heading to Samoa in January 2013 to refurbish a library and music room at St Mary’s College, Apia, Samoa. For more information on our journey to Samoa, please visit our website www.thevoicebnyg.weebly.com . Please complete your name and contact details, and other details below, and read the Conditions of Entry on the next page. Please make your payment via direct debit or send us a cheque made out to Banyo Nundah Youth Group. When completed, either email the form to thevoice@westnet.com.au or post to The Voice, 20 Donkin St Nundah, Qld, 4012. We will consider your application and send you a confirmatory email once your application has been accepted.

PedalYaker’s Name:

Address

Date of Birth:

Gender: Male Female

Phone:

Email (we will email you any updates related to the event):

Are you part of a PedalYak Team? If Yes, what is the Team Name?

Who can we contact in the event of an emergency? Name:	Relationship to you:	Phone Numbers:

Please list any medical conditions or medication that we should be aware of if you require medical assistance on the day.

If you are under 18, your carer/parent must understand the conditions of entry outlined below and give you permission to undertake the PedalYak. If under 18, please provide your parent/carer contact details below:	Carer Name:	Email:	Phone Number:

I will be (please tick one)

Kayaking 14kms or

Running Walking Cycling kilometres (Maximum of 14kms)

My Sponsorship Target is (please tick one) $50 $100 $200 $300 $400 $500 $1000 Other $

My shirt size is: . Note: To receive a shirt, you must have raised more than $200 in sponsorship (in addition to your entry fee).

Registration fee ($10 individual, $20 a family – non refundable, once application is accepted) paid by	Direct deposit on (date) (Bank Details for Direct Deposits: Account Name: Banyo Nundah Youth Group BSB: 064786	Account No.: 517010106)	online donation (go to http://www.givenow.com.au/banyonundahcatholicparish and follow the prompts –	enter in your name and the words “Entry Fee” when prompted to nominate someone to support	Cash. Office use – Received by . Receipt Number: Date:	Cheque made payable to Banyo Nundah Youth Group. Please post to: Banyo Nundah Catholic Parish, 20 Donkin St	Nundah, Q 4012.

The Important Small Print – Conditions of Entry

By lodging an application, you acknowledge that if your application to participate in the PedalYak is accepted, you understand and agree to abide by the following conditions of entry.

Kayakers: you will be over 12 years of age at the time of the PedalYak; will use your own kayak; can swim 25 metres fully clothed; understand that the Pedalyak involves a 14km kayak in tidal waters and that you are able to complete such a journey in under 4 hours; will wear your own life vest; carry a minimum of 500ml water; agree to stay in a designated group during the paddle; and follow the instructions or requests of any event coordinators.

Cyclists, runners, walkers: You will be capable of undertaking a 14km journey, or a 7km journey if you are doing one leg of the Pedalyak as part of a team; respect other users of the track, ensuring that you do not block the bikeway at any time; will not use the Criterium track or permanent shelter at Hedley Avenue (ok to use the toilets); are aware that there is no water along the track and will carry at least 500ml water with you; and follow the instructions or requests of any event coordinators, particularly when crossing any roads at the start of the event.

All participants:

you are a volunteer of the Banyo Nundah Catholic Parish for the duration of the event and are expected to act appropriately.

participation can be inherently dangerous and you are exposed to certain risks during the PedalYak, including personal injury, death and/or property damage, including, overexertion, equipment failure, dehydration, serious accidents and course and weather conditions.

you will be, at the time of the PedalYak, medically and physically fit for the event and unaware of any illness, injury or any other physical disability or impairment which may cause personal injury, death and/or property damage to you or anyone else while participating in the PedalYak.

you have provided details of any medical or physical condition that may be relevant if medical treatment is needed. You consent to receiving any medical treatment, including ambulance transportation, considered desirable by the event coordinators during or after the Event. In the event of an emergency, you authorise your personal details to be shared with appropriate parties, including, but not limited to, event coordinators, medical staff and your emergency contact.

photos of you may be taken and used in publications or on the internet related to the event and the Samoa trip.

you will have an entrant number written on your inside forearm or calf and that you will not start the event until you have registered on the day. You agree to register your completion of the event on the day before leaving the area.

Children of all ages are welcome although children under 12 must be accompanied by, and under the supervision of, a person aged 18 or over.

the PedalYak is held in an area with limited services - notably there are no toilets or drinking water points on the course between the boat ramp and Hedley Avenue.