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Rider Information & Consent Form for Juniors
If your place has been confirmed on an MTBG junior guided ride, please complete and return the form below using the 'submit' button at the bottom of the form. Thank you.
1. Rider's details
*
Indicates required field
Name
*
First
Last
Gender
*
Male
Female
Date of Birth
*
Age
*
Address
*
Postcode
*
Home Tel
*
Mobile
*
Email
*
What is your ethnic group?
*
White British
White Irish
Any other white background (please specify below)
Dual White and Caribbean
Dual White and Black African
Dual White and Asian
Any other mixed background (please specify below)
Asian or British Asian Indian
Asian or British Asian Pakistani
Asian or British Asian Bangladeshi
Any other Asian background (please specify below)
Black or Black British Caribbean
Black or Black British African
Any other black background (please specify below)
Chinese
Any other ethnic group (please specify below)
Further details
*
Do you consider yourself to have a disability/long term limiting illness?
*
Yes
No
If yes, what is the nature of your disability?
*
Visual
Physical
Multiple Disability
Hearing
Learning Disability
Other (Please specify)
Please specify
*
What is your previous mountain biking experience?
*
New to mountain biking
Regular mountain biker
Returning mountain biker (not cycled for 1 year or more)
Previous experience description
*
Where do you usually ride?
*
Have you ever participated in guided mountain bike rides?
*
Yes
No
Have you ever undertaken any cycle training or received any cycling coaching?
*
Yes
No
What would you like to achieve from the session/s?
*
2. Emergency Contact Details (please provide two points of contact)
Name 1
*
First
Last
Relationship to rider
*
Home Tel
*
Mobile
*
Name 2
*
First
Last
RELATIONSHIP TO RIDER
*
HOME TEL
*
MOBILE
*
3. Medical & specific needs
Please give details of any disability, medical or health conditions that might affect your participation in cycling and what support/modifications are needed.
*
Please list any medications you take on a regular basis. (Please ensure that you bring adequate supplies of medication and dosage for the duration of the ride.)
*
Are you allergic or sensitive to any medication (eg. penicillin), insect bites or food? ( If yes, please provide details)
*
Yes
No
Details
*
Please give details of any specific needs that the mountain bike leader should be aware of, and what support/modifications are needed.
*
4. Parent/Carer Consent
The following MUST be read and agreed by the parent/carer before the child may participate in the activity.
In the case of an emergency I agree to my child being given any medical, surgical or dental treatment, including general anaesthetic and blood transfusion, as considered necessary by the medical authorities present.
I understand about the risks involved with mountain bike riding and the insurance arrangements.
I consent to my child taking part in the ride, and, having completed section 3, declare my child to be in good health and physically able to participate in the ride/s.
I have noted where and when the participants are to be returned and I understand that I am responsible for my child getting home safely from that place.
I am aware of the levels of insurance cover.
I will ensure that any change in the circumstances (eg recent illness, medication or injury), which will affect my child’s participation in the visit will be notified to the mountain bike leader prior to the ride.
I will ensure that a parent or carer is contactable on the number provided in the emergency contact details for the duration of the ride and able to pick-up my child on time if required.
I HAVE READ AND UNDERSTAND THE POINTS ABOVE AND 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.
*
I agree
I disagree
I grant permission for photographs to be taken and used for promotional purposes
*
Yes
No
My child has permission to ride home on their own/with friends at the end of a ride
*
Yes
No
Name of Parent/Carer
*
First
Last
Date
*
5. Insurance Cover
The 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 the organiser of the ride.
6. Data Protection
MTB Guisborough respects individual privacy. The club obtains and processes “personal data” (as defined by the Act) for the purpose of administering its functions as a Community Amateur Sports Club and under relevant legislation. In addition, MTB Guisborough may use information for the purpose of fulfilling its statutory responsibilities under the Data Protection Act 1998.
Information will be kept secure and confidential and will only be disclosed to those parties who have a legal and legitimate need to know.
Do you wish to receive further information on Redcar & Cleveland Borough Council activity and other sporting activity?
*
Yes
No
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