Ad Hoc Booking Form - KSU Coaching

Rider Details

Name(Required)

First Last

Gender(Required)

Male

Female

Rather not say

DOB(Required)

Age(Required)

Please enter a number from 3 to 99.

Address(Required)

Street Address Address Line 2 City Post Code

Home Phone(Required)

Mobile Phone(Required)

Email(Required)

Enter Email Confirm Email

Cycling club/ group

Emergency Contact Details

Name(Required)

First Last

Relationship to rider(Required)

Home telephone

Work telephone:

Mobile(Required)

Medical and Specific Needs

It is your responsibility (or that of a parent/guardian/carer if under the age of 18) to provide the coach with details of any medical or health conditions, allergies, or dietary or other specific needs that might affect your ability to participate in cycling. Please note that a coach is unable to provide guidance or make decisions relating to medical or health conditions. Rather, if you have any concerns about participating in any form of physical activity, please consult with your GP before signing the consent form.

Please give details of any medical or health conditions, allergies, or dietary or specific needs that might affect your participation in cycling and what support/modifications are needed by the coach.

Please list any medications you take on a regular basis. (This information may be required by the emergency services in the event of an accident)

Arrival and Departure Arrangements if under 18

If under the age of 18, please give details of typical arrival and departure arrangements, eg the names of people you authorise to accompany the rider, and/or whether the rider is allowed to depart alone or with friends.

Rider Information

Previous cycling experience

What do you want to achieve from the sessions?

Please detail any other specific information that is relevant to participation in cycling activity sessions.

Name(Required)

First Last

Relationship to rider(Required)

This field is for validation purposes and should be left unchanged.