BMX Sports

Western Australia

2012 STATE Championships

Official entry FORM

ABN: 38 819 688 320

BMX Lic No. / Expiry Date / Surname / First Name / D.O.B / Transponder
No (if owned) / 2 Digit No
If applicable / 1st Class / 2nd Class / Total
Entries
432111 / 26/06/2011 / Rider / Champion / 30 /06 /1990 / TP-12345 / 01 / Elite Men / Cruiser / $140.00
TRANSPONDER HIRE / QTY / Transponder Hire @ $10 each
ENTRY SUBTOTAL / $
Important: Entrants only need to hire 1 transponder per Rider for this event.
MERCHANDISE ORDER / No Venue Sales
Name / Size / Qty / Long/Short
Sleeved (SS or LS) / Unit Cost / Total
MERCH SUBTOTAL
TOTAL COST
Is this your 10th / 15th Consecutive State titles? / Name
Entry Fees / Merchandise
Sprocket / $35.00 / Tshirts - Childs 6-16 Adult: SM - XXL
Challenge 20” Age Class / $65.00 / Short Sleeve / $30.00
Challenge 24” Age Class (Cruiser) / $65.00 / Long Sleeve / $35.00
Challenge 20” + 24” Cruiser / $100.00 / Child Sizing is quite small,
please ensure you order a size above
Championship Elite & Junior / $75.00
Transponder Hire / $10.00
CONTACT AND PAYMENT DETAILS
Name
Postal Address
Emergency Contact Person
Phone Number Mobile / Club
Sponsor
Name on Credit Card / Expiry date
Credit Card Number / Signature

BMX is a body contact, competitive sport wherein riders on bicycles practice and race according to the rules and regulations of the National Sanctioning Body, BMX Australia Inc., to which this club is affiliated through BMX Sports Western Australia Inc.

Conditions of entry to be signed by all entrants 18 years and over, or the parent/guardian of entrants 17 years and under. Persons entering the BMX Club, its facilities and environment do so at their own risk. BMX Sports WA Inc., The Host Club and its officials, contractors and voluntary workers accept no responsibility for any injury, damage or loss, however incurred, during activities associated with this event.

I give my consent for appropriate medical attention to be given. In signing this waiver I also agree to abide by the BMX Sports Western Australia Inc Code of conduct.

I/We understand and accept ALL conditions of Entry


APPLICANT/PARENT/GUARDIAN Signature: ______