27th - 30th May 2017

REGISTRATION

Please enter relevant details in this secure form to register your participation in ChallengeMD! Goldfields 2017

You will receive an email shorlty after completion of your registration with: full details of the ride and its requirements, a tax deductible receipt for $250 being your personal donation / registration and all relevant information on fundraising and what to bring on the ride.

An information night will be scheduled shortly at the MDA Head Office in North Melbourne where you will have an opportunity to learn more about ChallengeMD! Goldfields 2017 and the work undertaken by MDA in support of Programs, Services and Research.

.The MDA will respect and protect your privacy.

Please note, all fields require data entry.

ChallengeMD! Goldfields 2017 Registration for Information Kit
Title
First Name
Surname
Street
Suburb
State
Post
Email
Phone Home
Phone Work
Mobile Phone
Heard About It
Specific Rider Details
Rider Kit Size Jersey Knicks
Special Diet
Fitness Level
Cycling Club Affiliation
Medical Condition (any?)
Personal Profile for Fundraising Page
 
About me
You wll need to provide a head shot emailed for inclusion with your online profile
Registration Fee / Donation of $250
Credit Card Type Visa MasterCard
Credit Card No.
Expiry Date
Registration Fee Please note, $250 will be charged to your credit card
The MDA will respect and protect your privacy