Riders of Shaam Registration Form 2023

Riders of Shaam 2023 Registration Form

Please complete all sections of the application form. If you are attending the main event (A2C), you must fill in the section for your passport details. The fee for each event must be paid upon completion of the application on the donation page (you will be redirected automatically from this form). For any questions, please email us at ‘info@ridersofshaam.com’.

The four main events for 2023 will be:

Amsterdam to Copenhagen - A2C (males only)
- 420 Miles across Four Countries (Netherlands, Germany, Sweden & Denmark)
- Saturday 3rd June 2023 – Saturday 10th June 2023
- Registration Fee: £500
  - Flight and Accommodation included
- Minimum fundraising target: £3,000
Scafell Pike Trek (males only)
- England’s Highest Mountain
- Saturday 17th June 2023 (TBC)
- Registration Fee: £50
  - Transport from and to Leicester included
- Minimum fundraising target: £150
Fasted 500 (open to all)
- 500 km of cycling spread across the month of Ramadhan
- Ramadhan 2023
- FREE
- Minimum fundraising target: £500
Couch to 5K (open to all)
- Are you ready to challenge yourself to run a 5K from scratch? All whilst fundraising for a worthwhile cause!
- DATE TBC
- FREE
- Minimum fundraising target: £100
Are you signing up to cycle for the Amsterdam to Copenhagen (A2C) event?*

YesNo
Are you signing up to be support for the Amsterdam to Copenhagen (A2C) cycle ride?*

YesNo
Which other event(s) are you applying for? (Select all that apply)*

Scafell Pike TrekFasted 500Couch to 5K (running event)None of the above
Section 1: Applicants Personal Details
Full Name*

First Name Middle Name Last Name
Date of Birth*

DayMonth Year
Date
Contact Number*
Mobile
Email*

Confirmation Email example@example.com
Full UK Address*

Address

Street Address Line 2

City State / Province

Post Code
Each year, we release merchandise for all individuals who take part in our events. So that we can order an appropriate number in each size, please indicate your size even if you are not taking part in the main cycling event.
Cycling Jersey Size*
If your size is not listed here, please let us know via email after submitting your registration.
Hoody Size*
If your size is not listed here, please let us know via email after submitting your registration.
T-Shirt Size*
If your size is not listed here, please let us know via email after submitting your registration.
Section 2: Applicants Emergency Contact
Primary Point of Contact*
Full Name
Contact Number*
Mobile
Alternate Contact Number
Relationship to Applicant*
Secondary Point of Contact*
Full Name
Contact Number*
Mobile
Alternate Contact Number
Relationship to Applicant*
Section 3: Applicants Passport Details

Please enter all details exactly as they appear on your passport. If you have not selected to attend the main cycling event (A2C),you can skip this section.
Name

Given Names Surname
Passport Number
This is the nine (9) digit number found on your passport.
Date of Expiry
Your passport must have a minimum of 6 months validity from the return date. If you do not meet this requirement, it will result in you not being able to take part in the main event.
Please upload a copy of your passport photo page here.

function SvgDhtupload2(props) { return /* @__PURE__ */ react.createElement("svg", dhtupload_svg_extends({ width: 54, height: 47, xmlns: "http://www.w3.org/2000/svg" }, props), dhtupload_svg_path || (dhtupload_svg_path = /* @__PURE__ */ react.createElement("path", { d: "M40.213 10.172c1.897.21 3.68.738 5.35 1.58a15.748 15.748 0 0 1 4.374 3.242 15.065 15.065 0 0 1 2.951 4.533c.72 1.704 1.08 3.522 1.08 5.455 0 1.827-.28 3.654-.843 5.48-.562 1.828-1.379 3.47-2.45 4.929A13.39 13.39 0 0 1 46.669 39c-1.599.948-3.452 1.458-5.56 1.528H37.26a1.62 1.62 0 0 1-1.185-.5 1.62 1.62 0 0 1-.501-1.186c0-.457.167-.852.5-1.186.334-.334.73-.5 1.186-.5h3.848c1.44 0 2.75-.37 3.926-1.108a10.851 10.851 0 0 0 3.03-2.846 13.53 13.53 0 0 0 1.95-3.9 14.23 14.23 0 0 0 .686-4.321c0-1.582-.316-3.066-.949-4.454a11.623 11.623 0 0 0-2.582-3.636 12.857 12.857 0 0 0-3.742-2.478 11.054 11.054 0 0 0-4.48-.922l-1.212-.053-.37-1.159c-.878-2.81-2.292-4.998-4.242-6.562-1.95-1.563-4.594-2.345-7.932-2.345-2.108 0-4.005.36-5.692 1.08-1.686.72-3.136 1.722-4.348 3.005-1.212 1.282-2.143 2.81-2.793 4.585-.65 1.774-.975 3.68-.975 5.718h.053l.105 1.581-1.528.264c-1.863.316-3.444 1.317-4.744 3.004-1.3 1.686-1.95 3.584-1.95 5.692 0 2.39.8 4.462 2.398 6.219 1.599 1.757 3.488 2.635 5.666 2.635h4.849c.492 0 .896.167 1.212.5.316.335.474.73.474 1.187 0 .456-.158.852-.474 1.185-.316.334-.72.501-1.212.501h-4.849a10.08 10.08 0 0 1-4.374-.975 11.673 11.673 0 0 1-3.61-2.661 13.173 13.173 0 0 1-2.478-3.9A12.073 12.073 0 0 1 0 28.301c0-2.706.755-5.148 2.266-7.326 1.511-2.178 3.444-3.636 5.798-4.374.14-2.354.658-4.542 1.554-6.562.896-2.02 2.091-3.777 3.584-5.27 1.494-1.494 3.25-2.662 5.27-3.505C20.493.422 22.733 0 25.193 0c1.898 0 3.637.237 5.218.711 1.581.475 3.004 1.151 4.269 2.03a13.518 13.518 0 0 1 3.268 3.215 18.628 18.628 0 0 1 2.266 4.216Zm-11.964 13.44 6.22 6.85c.245.247.368.537.368.87 0 .334-.123.642-.369.923l-.421.263c-.211.246-.484.343-.817.29a1.544 1.544 0 0 1-.87-.448l-3.69-4.11v16.97c0 .492-.166.896-.5 1.212-.334.316-.729.474-1.186.474-.492 0-.896-.158-1.212-.474-.316-.316-.474-.72-.474-1.212V28.25l-3.584 4.005a1.544 1.544 0 0 1-.87.448.959.959 0 0 1-.87-.29l-.42-.264c-.247-.28-.37-.588-.37-.922 0-.334.123-.624.37-.87l6.113-6.746v-.052l.421-.422a.804.804 0 0 1 .396-.29c.158-.053.307-.079.448-.079.175 0 .333.026.474.079.14.053.281.15.422.29l.421.422v.052Z", fill: "none" }))); }

Cancelof
Section 4: Applicants Medical Declaration

When taking part in any event, you are accepting full responsibility of your fitness and health. You must take your doctors consent prior to taking part in any activity if you have declared any of the below to be true.

Do you have...*

	Yes	No
Heart / blood pressure problems?
Fractures, Tendon, Ligament, Cartilage Injury?
Back problems?
Physical or other disability?
Diabetes?
Mental or psychiatric illness?
Epilepsy or fainting?
Hospitalisation in the last two years?
Migraines?
Severe head injury?
Asthma, Bronchitis or Shortness of Breath?
Any allergies?

If you answered yes for allergies, please state them here.
Please skip this if you answered no to the previous question.
Are you suffering from any contagious diseases?*

YesNo
If you answered yes to the previous question, please specify it here:
Please skip this if you answered no to the previous question.
Are you a smoker?*

YesNo
Are you currently taking any medication?*

YesNo
If you answered yes to the previous question, please specify it here:
Please skip this if you answered no to the previous question.
Have you got any dietary requirements?*
Please enter 'N/A' if this is not relavant to you.
Please use this space to add any additional medical information.*
Please enter 'N/A' if this is not relavant to you.
Section 5: Terms and Conditions

Please make sure you have read and understood all the terms and conditions before submitting your application form.
If you require any assistance with completing the application form, please contact us on 'info@ridersofshaam.com'
Have you read and understood all the terms and conditions?*

YesNo
Do you agree to all the terms and conditions?*

YesNo
Applicants Signature

Clear
Date

DayMonth Year
Date
Upon submission, you will automatically be directed to the payment page. Payment for A2C and Scafell Pike shoud be made upon submision of this application form. Failure to do this will result in your application not being put forward to the next stage.

Please make sure you include your full name in the comment section when making the payment so that we can link your application to the correct payment.
Once you have made the registration payment, please upload a screenshot of the confirmation.

function SvgDhtupload2(props) { return /* @__PURE__ */ react.createElement("svg", dhtupload_svg_extends({ width: 54, height: 47, xmlns: "http://www.w3.org/2000/svg" }, props), dhtupload_svg_path || (dhtupload_svg_path = /* @__PURE__ */ react.createElement("path", { d: "M40.213 10.172c1.897.21 3.68.738 5.35 1.58a15.748 15.748 0 0 1 4.374 3.242 15.065 15.065 0 0 1 2.951 4.533c.72 1.704 1.08 3.522 1.08 5.455 0 1.827-.28 3.654-.843 5.48-.562 1.828-1.379 3.47-2.45 4.929A13.39 13.39 0 0 1 46.669 39c-1.599.948-3.452 1.458-5.56 1.528H37.26a1.62 1.62 0 0 1-1.185-.5 1.62 1.62 0 0 1-.501-1.186c0-.457.167-.852.5-1.186.334-.334.73-.5 1.186-.5h3.848c1.44 0 2.75-.37 3.926-1.108a10.851 10.851 0 0 0 3.03-2.846 13.53 13.53 0 0 0 1.95-3.9 14.23 14.23 0 0 0 .686-4.321c0-1.582-.316-3.066-.949-4.454a11.623 11.623 0 0 0-2.582-3.636 12.857 12.857 0 0 0-3.742-2.478 11.054 11.054 0 0 0-4.48-.922l-1.212-.053-.37-1.159c-.878-2.81-2.292-4.998-4.242-6.562-1.95-1.563-4.594-2.345-7.932-2.345-2.108 0-4.005.36-5.692 1.08-1.686.72-3.136 1.722-4.348 3.005-1.212 1.282-2.143 2.81-2.793 4.585-.65 1.774-.975 3.68-.975 5.718h.053l.105 1.581-1.528.264c-1.863.316-3.444 1.317-4.744 3.004-1.3 1.686-1.95 3.584-1.95 5.692 0 2.39.8 4.462 2.398 6.219 1.599 1.757 3.488 2.635 5.666 2.635h4.849c.492 0 .896.167 1.212.5.316.335.474.73.474 1.187 0 .456-.158.852-.474 1.185-.316.334-.72.501-1.212.501h-4.849a10.08 10.08 0 0 1-4.374-.975 11.673 11.673 0 0 1-3.61-2.661 13.173 13.173 0 0 1-2.478-3.9A12.073 12.073 0 0 1 0 28.301c0-2.706.755-5.148 2.266-7.326 1.511-2.178 3.444-3.636 5.798-4.374.14-2.354.658-4.542 1.554-6.562.896-2.02 2.091-3.777 3.584-5.27 1.494-1.494 3.25-2.662 5.27-3.505C20.493.422 22.733 0 25.193 0c1.898 0 3.637.237 5.218.711 1.581.475 3.004 1.151 4.269 2.03a13.518 13.518 0 0 1 3.268 3.215 18.628 18.628 0 0 1 2.266 4.216Zm-11.964 13.44 6.22 6.85c.245.247.368.537.368.87 0 .334-.123.642-.369.923l-.421.263c-.211.246-.484.343-.817.29a1.544 1.544 0 0 1-.87-.448l-3.69-4.11v16.97c0 .492-.166.896-.5 1.212-.334.316-.729.474-1.186.474-.492 0-.896-.158-1.212-.474-.316-.316-.474-.72-.474-1.212V28.25l-3.584 4.005a1.544 1.544 0 0 1-.87.448.959.959 0 0 1-.87-.29l-.42-.264c-.247-.28-.37-.588-.37-.922 0-.334.123-.624.37-.87l6.113-6.746v-.052l.421-.422a.804.804 0 0 1 .396-.29c.158-.053.307-.079.448-.079.175 0 .333.026.474.079.14.053.281.15.422.29l.421.422v.052Z", fill: "none" }))); }

Cancelof
Should be Empty:

Now create your own Jotform - It's free!Create your own Jotform

Section 1: Applicants Personal Details

Section 2: Applicants Emergency Contact

Section 3: Applicants Passport Details

Section 4: Applicants Medical Declaration

Section 5: Terms and Conditions