WeRide Guiding Consent

1. Rider Information & Consent Form
First Name *
Last Name *
Age *
Date of Birth *

Day Month Year
Date
Gender

Female Male
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Telephone

Area Code Phone Number
Mobile *

Area Code Phone Number
Email *
example@example.com
Previous mountain bike experience

New to Mountain Biking (Less than 12 months) Regular Mountain Biker (Over 12 month) Returning Mountain Biker (Not cycled for 3 months or more)
Have you participated in guided mountain bike rides before? *

Yes No
Do you ever cycle on the road? *

Yes No
If Yes how regularly?
Have you ever undertaken any cycle training or received any cycle coaching? *

Yes No
2. Emergency Contact Details
Name *

First Name Last Name
Relationship to Rider *
Home Telephone

Area Code Phone Number
Work Telephone

Area Code Phone Number
Mobile Telephone *

Area Code Phone Number
3. Disability
Do you consider yourself to have a disability? *

Yes No Prefer not to say
If yes, what is the nature of your disability?
Please provide details of any particular support you require
4.Medical Information
a) Do you suffer from any of the following conditions

Asthma Bronchitis chest problems Diabetes Fainting Migranes Heart Trouble Raised blood pressure Tuberculosis None
If yes to any of the above, please provide details
Do your suffer with Epilepsy? *

Yes No
If yes, a) what specific epilepsy syndrome has been diagnosed? b) What is the pattern of any seizure?
b) Do you suffer from any other condition requiring medical treatment of medication? *

Yes No
If yes, please provide details
c) Are you allergic or sensitive to any medication (e.g penicillin), insect bites or food? *

Yes No
If yes, please provide details
d) Have you been immunised against the following diseases? - Poliomyeltis *

Yes No
d) Have you been immunised against the following diseases? - Tetanus (lock Jaw) *

Yes No
If yes to tetanus, please give date (if known)

Month Day Year
Date
e) Are you taking any form of medication on a regular basis? *

Yes No
If yes, please give full details, indicating the type of medication and dosage
Please ensure that you bring adequate supplies of medication and dosage for the duration of the activity.
f) To the best of your knowledge, have you been in contact with any contagious or infectious diseases, or suffered any recent condition that may become infectious or contagious? (This include COVID 19) *

Yes No
If yes, please provide details
g) Please supply any additional information that the mountain bike leader should be aware of (eg recent illness, medical information special requirements etc) which may affect the full range of activities in this ride, and what support/modifications are needed
Declaration
In the case of the applicant being over 18 years of age, the following must be read and signed: I declare that the above information is correct and that the person in charge has my permission to authorise medical treatment in an emergency. If I have answered "yes" to one or more of the above questions in Section 4, I should seek medical advice before attending a ride. I agree to tell the mountain bike leader if there is a change in my medical condition. I understand that this information will be shared with other mountain bike leaders and that I cycle at my own risk.
Signed

Clear
Date

Day Month Year
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. Parental/Carer Consent
In the case of the applicant being under 18 years of age, the following MUST be read and signed by the parent/carer and returned to the mountain bike leader together with the completed Rider Information Form 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 have read the attached information provided about the proposed activity and the insurance arrangements. I consent to my child taking part in the ride, and, having read the information sheet, declare my child to be in good health and physically able to participate in any activities mentioned.

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.

Iam 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 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.
Signature of Parent/Carer

Clear
Date

Day Month Year
Date
Name of parent/carer in block letters
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Data Protection Statement
British Cycling respects individual privacy and has notified (registered with) the Information Commissioner, who is responsible for the administration of the Data Protection Act 1998 (the Act British Cycling obtains and processes "personal data" (as defined by the Act) for the purpose of administering its functions as a National Sporting Governing Body and under relevant legislation. In addition, British Cycling 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.

British Cycling, Stuart Street, Manchester M11 4DQ T +44 (0) 161 274 2000 britishcycling.org.uk
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1. Rider Information & Consent Form

2. Emergency Contact Details

3. Disability

4.Medical Information

Declaration

5. Insurance Cover

6. Parental/Carer Consent

Data Protection Statement