Registration Form

TEAM Registration

* Indicates required field

Team Leader/Rider Name *

First

Last

Number of Scooters in Team *

Number of Riders in Team *

Registration Plate Number *

Yes I would like a T-Shirt (State below SIZE-HOW MANY) *

Email *

Phone Number *

Choose A Charity *

Hospice Southland Southland Charity Trust

I have read & agreed to the Terms & Conditions *

YES

Submit