Canberra Cycling Club Junior Development Program Registration Form

Junior Development Program (Winter Road)

Program Dates: Apr 2012 - Sept 2012

Program Locations: Stromlo Forest Park and John's Garage

Participant Information

* Name

* Street Address

* Suburb

* State

* Postcode

* Phone

* Email Address

* Date of Birth

* Choose a Program

CCC members - $220

Non-CCC members - $250

CA license no

* CCC Winter Jacket

* Payment Method

Cash

Cheque - payable to Canberra Cycling Club

Direct Debit - St George Bank Account No: 040 016 541 BSB: 112-908 Ref: GSICP

Emergency Contact

* Name

* Phone

* Relationship to Participant

Please complete the section below.

I give permission for the child listed above to participate in the Canberra Cycling Clubs, Junior Development Program.
I acknowledge that my child participates in the 2012 CCC Junior Development Program at his/her own risk. I release, discharge, indemnify and will keep Canberra Cycling Club, its Members, Officials and Staff indemnified from and against all actions, claims, liabilities, consequential loss and/or damage and all legal and other costs or expenses, suffered or incurred by my child as a result of their participation in the 2012 CCC Junior Development Program.

* Name

* Phone

* Relationship to Participant

Comments/Special Needs:

* Indicates Response Required


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