Cyclist Registration Form – Wheels for Wellbeing

Cyclist information

Name*

First Last

Nick name / known by

Gender*

Male
Female
Transgender
Prefer not to say

Date of birth*

Home address*

Or name & address of centre / organisation arranging your attendance:(Centre must be registered with Wheels for Wellbeing)

Street Address Address Line 2 City Post code

Phone*

Would you like to be alerted by text of any session cancellations?*

Yes
No

Email

Would you like to receive our newsletter and updates via email?*

Yes
No

Are you coming with a centre/day care/school group?*

Yes
No

Name of group*

Emergency Contact

Name*

First Last

Relationship to cyclist*

Phone number*

Current level of activity in a typical week. This is physical activity which makes you feel warmer and raises your heart rate.

How is your health in general?*

On how many days do you do at least 10 mins of moderate physical activity?*

On how many days do you do at least 30 mins of moderate physical activity?*

Impairment*

Ethnicity*

Please specify*

Please tell us - Why do you want to cycle with us? (select all applicable options)

Please specify*

Please tell us – How did you find out about us? (select 1 option only)

Please specify*

Declaration

Must be signed before cycling with us

I understand that the sessions will be led by experienced and qualified cycle trainers
I am aware that they will offer me guidance, advice and support with regard to cycling and cycling related matters and I agree to cycle under their supervision
I have read and agreed to Wheels for Wellbeing’s Ground Rules and so have all the people who accompany me
I accept that there may be an element of risk in all activities, but am satisfied to proceed with the session
I confirm that I have the consent of my emergency contact to share his/hers personal details

Photography consent*

I agree
I do not agree

Wheels for Wellbeing would like to ask for the right to use photograph/s or film taken of you at our cycling sessions.These may be used and edited for all general marketing purposes to promote inclusive cycling, including website and social media content, leaflets, posters, press releases, fundraising appeals, newsletters and articles.We cannot pay or reward you for providing this authorisation.

Tick one*

(Over 18 only) I will attend session independently and take responsibility for my own safety during sessions. I have provided contact details for the person you should contact on my behalf in the event of an emergency.
I will always come with someone to support me during cycling sessions and they will assist me in the event of an incident during the session. Each person who supports me will register their details with Wheels for Wellbeing.

Your confirmation*

First Please check to accept the Wheels for Wellbeing cyclist sessions terms

If accepting on behalf of someone else, please indicate your relationship to them

Parent / guardian
Care worker
Teacher
Other