Name:
Date of Birth:

Contact Details:
Address:
Email:   
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How did you hear about Miles Per Hour? 

Which federal electorate do you live in?  To find the name of your electorate, go to http://www.aec.gov.au/esearch/main.htm and type in your postcode: 

Which organisation or campaign are you a member of?  (please check)
Oaktree Foundation (If you are a member of the Oaktree Foundation, you will receive info about their National Conference happening on 18/19 November).
The Micah Challenge
United Nations Youth Association
Jubilee
World Vision
Christian World Service
Aidwatch
Vision Generation
Oxfam
other, please specify :
new to the challenge and interested to come on board

DIETARY REQUIREMENTS
Please detail any specific dietary requirements you have (eg vegetarian, vegan, halal, kosher, diabetic, allergies, etc.) below:

INTERESTS
Please describe briefly any interests and experience you have related to this trip.  For example, you may be studying development studies, done overseas volunteer work or are part of a school group.  Experience is not required, but we just want to get a picture of our participants.
  

TYPE OF TRANSPORT (tick option boxes):

Bus:
from Brisbane leaving thurs 16 arriving back Mon 20 Nov
from Sydney  leaving wed 15 arriving back am Mon 20
from Adelaide leaving wed 15 arriving back Sun 19 November pm
from Canberra leaving thurs 16 arriving back Sun 19 November pm

Plane: 
I will be booking a cheap flight soon and getting there individually by plane
Group Booking:  I would like to join other campaigners on a group booking from my capital city; to be arranged by my state coordinator.  This flight would leave on the morning of Thurs 16 November and return on the afternoon of Sunday 19 November.   I realise that this flight will not be confirmed until late September and thus may have a different price arrangement. NB: This option is currently only available from Perth, Brisbane, and Hobart.

Train:
I am interested in taking the train from Sydney to melbourne  (TBC)

Cycling:
I would like to receive information about cycling down to Melbourne with other campaigners.