Registration * Email
* Password
*Must be between 6 - 10 characters
* Password Confirm
*Re-enter password
* First name
*First name
* Last name
*Last name
Mobile
Mobile
Phone
Phone
Donate I would like to donate to support Lifeline with an additional: $10 $25 $50 $100 Sorry, not today
Date of Birth *
/
Select Day
/
Select Month
Male
Select Year
Female
*Postal Address
I would like regular newsletter updates
Unit
Unit
*Street name
*Street name
*Street Number
*Street Number
*Suburb
*State
*Select
*Postcode 0000
*Who are you registering for?
Register
Yourself Someone else over 18 Someone else under 18 Group or organisation
How did you hear about us? *Which entry are you running in? Hill Walk - 3 laps Kids
$20
Hill Walk - 5 laps Under 18’s
$25
Hill Run - 3 Laps Under 18’s
$30
Hill Run - 10 laps Over 18’s
$40
Saving lives Lifeline Ballarat PO Box 645 Ballarat Vic 3353 5332 1009 info@lifelineballarat.com.au
Click here to view the Terms and Conditions
I have read and accept the Terms and Conditions of the Lifeline Ballarat Dana 100 Charity Challenge
Additional information
*Suburb
Please send me my results and photo for an additional $15