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Adult Rider Information and Consent Form

Please fill in the form below and submit with the riders details and emergency information

* For under 18’s please click here

Section 1: Rider's Details

First Name: (required)

Last Name: (required)

Gender: (required)
MaleFemale

Date of Birth: (required)

Age: (required)

Telephone:

Mobile: (required)

Email address: (required)

Previous Mountain Bike Experience

Experience: (required)
New to Mountain BikingRegular Mountain BikerReturning Biker (not cycled for over 3 months)

Have you participated in guided mtb rides before: (required)
YesNo

Do you ever cycle on the road?: (required)
YesNo

If yes, how regularly?:

Have you ever undertaken any cycle training or received any cycle coaching?: (required)
YesNo

Section 2: Emergency Contact Details

First Name: (required)

Last Name: (required)

Relationship to rider: (required)

Telephone:

Mobile: (required)

Work Number:

Section 3: Disability

Do you consider yourself to have a disability?: (required)
YesNoPrefer not to say

If yes what is the nature of your disability?:

Please provide details of any particular support you require:

Section 4: Medical Information

a) Do you suffer from any of the following medical conditions?: (required)

Asthma YesNo

Bronchitis YesNo

Chest problems YesNo

Heart trouble YesNo

Raised blood pressure YesNo

Diabetes YesNo

Fainting YesNo

Migraines YesNo

Tuberculosis YesNo

If yes to any of the above please give details:

Do you suffer from epilepsy?: (required)
YesNo

If yes, what specific epilepsy syndrome has been diagnosed?:

If yes, what is the pattern of any seizure?:

b) Do you suffer from any other condition requiring medical treatment or medication? (required)

YesNo

If yes please provide details:

c) Are you allergic or sensitive to any medication (eg penecillin), insect bites, or food? (required)

YesNo

If yes please provide details:

d) Have you been immunised against the following diseases? (required)

Poliomyelitis YesNo

Tetanus YesNo

If yes to tetanus please give date (if known):

e) Are you taking any form of medication on a regular basis? (required)

YesNo

If yes, please give full details, indicating the type of medication and the dosage:

* Please ensure that you bring adequate supplies of medication and dosage for the duration of the activity

f) To the best of your knowledge, have you been in contact with any contagious or infectious diseases, or suffered and recent condition that may become infectious or contagious? (required)

YesNo

If yes, please provide details:

g) Please supply any additional information that the mountain bike leader should be aware of (eg recent illness, medical information, special requirements etc) which may affect the full range of activities in this ride and what support/modifications are needed :

Section 5. Insurance Cover

This ride is insured in respect of legal liabilities (third party liability). However participants have no personal accident cover unless they have been specifically advised of this in writing by the organiser of the ride. It is the participants responsibility to arrange for any extension of insurance cover unless advised differently by the leader or organiser of the ride

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 RISK ASSESSMENTS. COPIES OF WRITTEN RISK ASSESSMENTS ARE AVAILABLE ON REQUEST.

DECLARATION

I declare that the above information is correct and that the person in charge has my permission to authorise medical treatment in an emergency. If I have answered "yes" to one or more of the above questions in Section 4, I should seek medical attention before attending a ride. I agree to tell the mountain bike leader if there is any change in my medical condition. I understand that this information will be shared with other mountain bike leaders and that I cycle at my own risk.

Please tick box to confirm that you have read and accept the above terms

DATA PROTECTION STATEMENT

British Cycling respects individual privacy and has notified (registered with) the Information Commissioner, who is responsible for the administration of the Data Protection Act 1998 (the Act). British Cycling obtains and processes “personal data” (as defined by the Act) for the purpose of administering its functions as a National Sporting Governing Body and under relevant legislation. In addition, British Cycling may use information for the purpose of fulfilling its statutory responsibilities under the Data Protection Act 1998. Information will be kept Information will be kept secure and confidential and will only be disclosed to those parties secure and confidential and will only be disclosed to those parties who have a legal and legitimate need to know.

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