GOforGOLD Cycling Bunch
Membership Form
Do you want to be a Social Member or Riding Member?
*
Social Member
Riding Member
PERSONAL DETAILS
Name
*
First Name
Last Name
Email
*
Mobile Phone
*
Date of Birth
-
Year
-
Month
Day
yyyy-mm-dd
Address
Street Address
Street Address Line 2
City
State
Post Code
Blood Type
AusCycling Licence Number
*
Required to join the bunch
AusCycling Licence Expiry Date
*
-
Year
-
Month
Day
yyyy-mm-dd
Do you have any medical conditions that might affect your ability to ride (e.g. heart disease, diabetes, epilepsy)? This information will be kept confidential and only made available to ride leaders/coaches.
*
If your health circumstances change please notify Go for Gold using the form on the application site.
Do you carry medication for any of the above?
Yes
No
CONTACT DETAILS
Emergency Contact Details
*
Contact 1
Contact 2
Name
Relationship
Home Phone
Mobile Phone
CYCLING HISTORY and EXPERIENCE
How often do you currently...
*
None
1x week
2x week
3x week
>4x week
Ride your bike?
Engage in non-cycling exercise?
How do you rate your current level of confidence about...
*
1 (Low)
2
3
4
5 (High)
Riding?
Riding in traffic?
How would you rate your level of cycling experience?
*
Beginner
Intermediate
Experienced
Olympian
How would you rate your current level of fitness?
*
Below Average
Average
Good
Very Good
Have you ridden in a cycling bunch before on the road?
*
Yes
No
If yes, when and where?
*
Are you able to perform the following?
*
Yes
No
Remove/replace water bottles whilst riding?
Perform hand signals whilst riding?
Change gears?
Ride using clip in pedals (cleats)?
Ride out of the saddle?
What are your expectations of the GOforGOLD Cycling Bunch?
*
DECLARATION and INFORMED CONSENT
Membership Agreement
*
I have read, understand and agree to the terms and conditions in the Membership Agreement for participation / membership with the GOforGOLD Cycling Bunch www.gfg.news/bunch
Code of Conduct and Bunch Etiquette
*
I have read, understand and agree to abide by the Code of Conduct and Bunch Etiquette for participation in the GOforGOLD Cycling Bunch www.gfg.news/bunch
Bike Safety
*
I understand that it is my responsibility to bring my bike well maintained, with all safety gear – including Australian Standards helmet & brakes in good working order.
If I am in doubt as to the maintenance status of my bike, I will have it assessed, and if necessary, repaired by an experienced bike mechanic / bike shop BEFORE the ride.
Signature
Date
*
-
Year
-
Month
Day
yyyy-mm-dd
Submit
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