pedalTherapy Registration Form

Registration Form for new students

Please fill in the form below prior to your first session
Full Name *

Prefix First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Phone Number *

Area Code Phone Number
E-mail *
Emergency Contact (name, relationship and phone number) *
Do you have any unique medical needs or concerns that I should know about? (your response is confidential) *
How did you hear about pedalTherapy?
How long have you been mountain biking? Years, months, weeks, days, never?
Do you enjoy other forms of cycling? If so, for how long? Road, BMX, commuting, etc...
Have you ever competed in a race or participated in a cycling event? Which ones and when?
What goal(s) do you have? Is there a specific skill or skills you'd like to focus on?
I often take photos / videos of my clients showing off their new skills and share via my social media channels (first names only, flattering photos only!). However, I also respect your privacy, so please let me know your preference:

Heck yeah! I'd love to brag to my friends and be able to show them what I learned! I appreciate the consideration. Let's keep this between you and me.
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Registration Form for new students