Become a Jafakid!

Jafakid #1

First Name Family Name
Date of Birth Mobile #
Shirt Size    
Medical Condition/Allergies Current Medication

Jafakid #2

First Name Family Name
Date of Birth Mobile #
Shirt Size    
Medical Condition/Allergies Current Medication

Jafakid #3

First Name Family Name
Date of Birth Mobile #
Shirt Size    
Medical Condition/Allergies Current Medication

Address and Contact Details

Street Address Email Addresses
for updates and information
One per line

Contact Details for Parent(s)/Guardians

Name Landline # Mobile #

I acknowledge that cycling is an inherently dangerous sport in which I participate at my own risk and that the Department of Cycling Club ('the Club') is an organisation formed to advance the sport of cycling, the efforts of which directly benefit me. On behalf of myself, my heirs, assigns and personal relatives, I waive, release, and forever discharge the Club, its officers, agents, members, sponsors, promoters, and affiliates whosoever form any and all liability, claim, loss, cost or expense arising from or attributable in any legal way to any action or omission or act of any such person or organisation or execution of any racing or sporting event, including travel to and from such event, in which I may participate as a rider, team member or spectator. I agree to wear a helmet whenever I am riding with the Club, to obey road rules, and to follow Club rules. To the best of my knowledge I have no physical condition which would interfere with my ability to participate in or attend any such event, or which would endanger my health. I consent to the information supplied on this form being incorporated into the Club's register and for it to be available to Club Members to contact each other on club related matters. I also consent for photos showing myself taken during cycling events to be displayed on the club website. I may request for a photo to be removed by contacting the club website (info@jafakids.com).

Fees

Item Amount Number Total
Coaching Fee
First two youth riders from each family are $120 each, subsequent youth riders are $60 each
$120.00 $120.00
$60.00
Department of Cycling Membership
DoC is our umbrella club and all Jafakids and parent/adult riders must be DoC Members or Associate members
Associate members must also have membership of another Bike NZ Affiliated Club*
Youth $40.00
Family $110.00
Adult $65.00
Associate $15.00
Woodhill Annual Pass
for Jafakids Only
$55.00
Riding Shirt
  • for Jafakids Only - one shirt per rider at this subsidised rate.
  • All Jafakids must wear a Jafakids shirt on rides.
  • Please note size required with the riders details above
$40.00
  Total to pay: $120.00

* For those choosing Associate Department of Cycling Membership

Declaration: All riders on this form are fully paid up and current members of a Bike NZ affiliated club and will remain so for the duration of this Jafakids membership period (Oct 2017 - Sept 2018).

Club Name:

Payment Internet Banking
Jafakids Account: ASB 12-3085-0471250-00
Please use your full name and mobile number as reference codes.
Questions/Further Information? Email us: info@jafakids.com or visit the website: www.jafakids.com
Are you happy to receive Newsletters from the Club? Yes
No
Are you happy to receive promotional offers from our Sponsors? Yes
No
Can we use your race results and photos in newsletters and promotional activities? Yes
No

PRIVACY: The information collected in this form will be used in accordance with the principles of the Privacy Act of 1993. It will only be used in a lawful purpose connected to the Club. By submitting this form, you acknowledge your rights to view and amend the information at any time.

This form has been completed by