Horatio's Garden

Cycle

 

Handbike registration for the Chalke Valley Cycle Ride 2016

Please complete the form below to register.






If you are between 12 and 16 years you must have a responsible adult with you on the ride.











We will be in regular contact about your trip and prefer to contact you by email to save paper.

Data Protection






NB: If your BMI is over 25 it does not mean that you cannot take part in this challenge but Horatio's Garden may contact you to discuss training and possible difficulties you will face on the ride.




In the event of an accident or illness whilst on the trip, I hereby give permission for Horatio's Garden to initiate medical treatment and to inform my next of kin/emergency contact (as detailed on my registration form) if appropriate.

To the best of my knowledge I confirm that my mental and physical health and fitness is good and that the information I have provided in this questionnaire is a true and accurate description of my medical history and current condition. I understand that by giving false information I endanger both my own safety and that of others on the trip. I agree to take with me sufficient supplies of medication needed for my current medical condition and for any condition which I have had previously which may reasonably be expected to re-occur.

I agree that Horatio's Garden or medical staff employed by them may approach my GP to verify the information on this form and attain some further details as they think necessary and that my GP may release such information to them.

I understand that Horatio's Garden cannot accept any liability or expenses resulting from any illness, injury or other untoward occurrence arising from any undisclosed medical condition (other than to the extent that death or personal injury arises as a result of its negligence). I also understand that failure to disclose a pre-existing medical condition could invalidate my travel insurance and that I am responsible for declaring any pre-existing medical conditions directly to the insurance company prior to departure.

If you are 65 or over, have answered 'yes' to one or more of the questions above, have a bmi of 35+, we must ask you to print out this medical questionnaire and ask your GP to sign it. This does not necessarily adversely affect your chance to take part.

If you do not have access to a printer and wish us to send the questionnaire to you, or if you wish to ask us about getting a signature from your GP, please call Horatio's Garden on 07429 140918.
NB: We will need to be in receipt of your signed medical form within a month of this date.



Download and print the Medical Questionnaire




The person you would like us to contact in case of emergency. This should not be someone who will be on the challenge with you