Cycle the official 2016 Clipsal 500 Adelaide Circuit!Your opportunity to participate in an exclusive cycling event with Stuart O’Grady on the Clipsal 500 Adelaide Circuit.

Date Friday morning of the 2016 Clipsal 500 Adelaide (dates to be confirmed).

All participants will:— receive an invitation to breakfast following the Stuart O’Grady Asthma Classic 2016 to be served in a venue close to

the track and hosted by Stuart O’Grady. — receive a pass to attend one day of the Clipsal 500 Adelaide event (Either Thursday or Friday TBC).— receive the official Stuart O’Grady Asthma Classic event jersey.

Eligibility To be eligible to participate in the 2016 Stuart O’Grady Asthma Classic, each rider will be required to fundraise a minimum of $3,000 for Asthma Foundation SA. All proceeds to support the Paediatric Asthma Educator Program. An initial registration fee of $100 [together with a donation of $400] is required to secure your participation as one of the 50 riders, which will be credited toward your fundraising target. The initial payment must be received before organisers will accept and confirm your entry.

Fundraising incentives, event prizes, and further information will be available online from 2 Septmeber 2015.

asthmaaustralia.org.au/Clipsal500

ASTHMA CLASSIC

NATIONALCYCLING EVENTS

OFFICIAL CHARITY OF THE 2016 CLIPSAL 500 ADELAIDE

Entry Type

First Name

Date

CA Member Number

Email Address

Date of Birth

Cycling Club

State

Phone Number

Gender

Tax-deductible donation of

Last Name (CAPITALS)

Stuart O’Grady Asthma Classic Registration Form

TERMS AND CONDITIONS: [1] This event is a recreational fundraiser for Asthma Foundation SA. [2] Riders must commit to raising a minimum of $3,000 by COB 01/02/2016 in order to be eligible to participate in the ride. After making an initial payment of $500 (initial registration fee of $100 together with a donation of $400) toward your fundraising target to secure one of the 50 positions available, the participant will be required to raise a further minimum amount of $2,500 for Asthma Foundation SA online or offline. Asthma Foundation SA will develop an Everyday Hero fundraising page to assist participants with fundraising. Donations over $2 are tax deductible. A tax deductable receipt for your donation(s) will be sent to the address indicated on the registration form. [3] The field of participating riders will join Stuart O’Grady for a 40 minute ride plus one lap ride around the official Clipsal 500 Adelaide circuit. The ride will take place on the Friday morning of the 2016 Clipsal 500 Adelaide (Date TBC). [4] A complete list of finishing positions and times will be published on the Asthma Australia website and in the Adelaide Advertiser within one week of the event date. [5] Monies raised from the event will support Asthma Foundation SA’s ‘Paediatric Asthma Education Program’. [6] The rider raising the most money will wear the Stuart O’Grady Asthma Classic Yellow Leader’s jersey, the second highest fundraiser will wear the Green jersey and the third highest the Polka-Dot jersey. All other riders will be required to wear the official event jersey (supplied by Asthma Foundation SA). [7] Entries will be accepted on a first in basis once the entry fee is received. All acceptances will be notified and confirmed via email. The Event Director retains the right not to accept or reject event entries. It is anticipated the riders will cover approximately 35 kilometres at speeds of up to 40 kilometres an hour. [8] It is the responsibility of the rider to ensure he or she is at a necessary fitness level to enter this event. Riders participate at their own risk. Asthma Foundation SA does not accept any liability. [9] Riders must have a minimum of a ‘RECREATIONAL’ License with Cycling Australia, which can be organised for you. Recreational Licence information & Membership can be obtained by contacting Cycling SA 08 8260 1800. [10] By completing and returning this form you are agreeing that you will abide by the Cycling Australia’s Technical Regulations and By-laws. In order to participate, completed forms are to be emailed to info@asthmasa.org.au by the close of business 01/02/2016.

Tax-deductible donation ofRegistration Fee

Please debit my Visa Mastercard Amex Diners

The Asthma Foundation of South Aust BSB: 035 212 Account: 242511

Card Number CVV Expiry (MM/YY)

Name on Card Signature Date of Birth

Credit card payment:

Bank transfer:

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$400 $3,000 my choice $ $100

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Yes, please accept my registration

CLIP

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Complete and return this form to info@asthmasa.org.au by 1 February 2015. Eligibility will be on a first-in best-dressed basis.