Name
*
First Name
Last Name
Email (or email of parent/carer)
*
Mobile Telephone Number (or number of parent/carer)
*
Date of birth
*
Address
Fitness Level
*
If riding an e-bike then select fitness level when riding an e-bike
Skill level
*
Emergency contact name
*
Emergency contact phone number
*
Emergency contact email address
Have you been diagnosed, or suffer from, any of the following conditions
If yes to any of the above, please provide details
Do you have any allergies? If yes, please provide details
Are you allergic to any medication? If yes, please provide details
Are you currently taking any medication? If yes, please provide details
Do you have any specific needs that might affect your participation in cycling or the support required from the ride leader (for example difficulty hearing)
Children under the age of 18
All Children under the age of 18 must be accompanied by a responsible adult for the duration of the guided cycle ride. I declare that I will remain responsible for the child throughout the cycling activity, and that I have the permission to authorise medical treatment for the child should it be required.
Name of responsible adult
Declaration
*
I accept that there is an inherent risk of injury in participation in cycling activities. Risk can be reduced to acceptable levels by implementing appropriate controls.
