Member eForm – Horwich Ride Social

Name *

Phone *

Date of Birth *

Email Address

Postcode *

Emergency Contacts

Name *

Post Code *

Phone *

Relationship to participant *

Health and Safety

Gender *

Ethnicity

I give permission for the use of photos or other media featuring me (or the person for whom I'm completing this form) *YesNo

I give permission to receive emails from Cycling UK via Upshot *YesNo

Cycling information (for new participants)

How much do you agree with the following statement? “I intend to cycle more in the next few months" *

Roughly, how often do you cycle? *

How do you normally travel to work or education *

How do you normally travel for other everyday activities *

Moderate physical activity is any activity that raises your heart rate and makes you breathe faster. How much moderate activity have you done in the last week? *

Do you have any long-term physical or mental health conditions or illnesses lasting or expected to last 12 months or more? *

You are disabled under the Equality Act 2010 if you have a physical or mental impairment that has a "substantial" or "long-term" negative effect on your ability to do normal daily activities. By this definition, do you consider yourself disabled? *

If yes, please feel free to provide further information that may be relevant or useful to help us understand any challenges you may face.

Confirmation

Privacy Notice

I accept the organisation's Terms & Conditions and Privacy Policy *Yes

Signature