This is an electronic application form. One Application for Entry Form is required per rider. Please fill in all questions then submit by clicking on ‘Done’ at the end of the form.

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* 1. Personal Details

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* 2. PWC Details

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* 3. Preferred Grouping

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* 4. Please answer Yes or No to the following

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* 5. Men's shirt size?

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* 6. Ladies shirt size?

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* 7. Rash shirt required at $65?

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* 8. Medical Information (Strictly Confidential)

Please send a recent head & shoulders photo by email to burfoot@xtra.co.nz.
This will be used for ID purposes.
DECLARATION

I intend to pledge a minimum donation of $1,500 plus an entry fee of $55 (incl GST) to the Melanoma Foundation.

I will make payments as per the following:
* $55 with this application
* $500 donation on or before 31st January 2015
* $1000 final donation on or before 28th February 2015
A total of $1,555 (or $1620 if purchasing a rash shirt)

I understand that in the event of an application being received after 31st January 2015 the minimum donation will be $2,000.

In addition, I agree to pay a provisions levy (amount not to exceed $600). The provisions levy will include: Most meals, entertainment and merchandise. (The provisions levy will be set to cover actual costs).

I understand that acceptance of entries in the 2015 Melanoma Foundation Ski-nZ is at the absolute discretion of the Melanoma Foundation and that receipt of this Application Form does not guarantee a place on Ski-nZ. I also understand that my team and I enter entirely at our own risk and that we will each sign an Indemnity Form prior to the event that will also include permission to receive marketing and promotional material / information from the Melanoma Foundation as well as permission to include any photography / film footage of me / the team / and or, PWC/vehicle.

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* 9. All entrants must be over the age of 18!

PAYMENT OPTIONS

Online donations: Secure online donating for the donation component is easy at www.melanoma.org.nz/Give-Support/Donate-Online (write Ski-nZ in the comments box).

Online Application Fee payment (GST incl) www.melanoma.org.nz/Give-Support/Shop-Online/

Cheques should be made payable to: The Melanoma Foundation of New Zealand

Credit card (see next question)

NB - If you set up a Fundraise Online fundraising page, when it comes time to debit your credit card, if your Fundraise Online page total exceeds the amount owing for donations, your card won't be debited. This does not apply for the Provisions Levy though, as that can not be covered by online donations.

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* 10. Please select & complete 1 of the following 3 credit card options

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* 11. CREDIT CARD DETAILS

TAX DEDUCTIBILITY

All donations will receive a receipt. Donations made to the Melanoma Foundation may be eligible for a tax rebate. This does not apply to the $55 application fee which is GST inclusive. A tax invoice/ receipt will be provided for this.

IMPORTANCE OF SPONSORSHIP

Sponsorship is vital to the success of the Event and in turn the on-going achievements of the Melanoma Foundation. Without the backing of sponsors there would not be an Event. Their generosity enables entrants to be involved in a great adventure with a good cause without too much expense to themselves. Entrants should ensure that sponsors get an acceptable return for their investment.

GENERAL

• This event is NOT about a race or rally in the usual sense.
• There are no cash prizes.
• Awards are presented to those who have raised the most money and to those who entered into the spirit of the Event and other such reasons.

Event Director: Jeremy Burfoot
Phone: +64 21 213 2056
Email: Burfoot@xtra.co.nz

THE MELANOMA FOUNDATION OF NEW ZEALAND
Postal address: PO Box 31-167, Milford, Auckland 0741
Phone: 09 449 2342 Freephone: 0800 4 MELANOMA (0800 463 526)
Email: info@melanoma.org.nz
Physical address: Level 1, 52 East Coast Rd, Milford, Auckland

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