2020 Credit / Debit Card Black Shuck Challenge Payment Form

Black Shuck Challenge Registration Form
Please complete all rider details below before clicking PAY NOW.

Thanks Norfolk Cycling Events

My Products *

Black Shuck 3 Loops (90 miles) £ 23.50 GBP

Quantity

Black Shuck 2 Loops (60 miles) £ 19.50 GBP

Quantity

Black Shuck 1 Loop (30 miles) £ 15.50 GBP

Quantity

Black Shuck 10 miles £ 10.00 GBP

Quantity

Black Shuck Under 16's £ 1.95 GBP

Quantity

Total £ 0.00 GBP

1st Rider Form
Full Name *

First Name Last Name
E-mail *

Confirmation Email
Address *

Street Address

Street Address Line 2

City / Town County

Postcode Country
Rider Phone Number *

Phone Number
Emergency Contact Name *

First Name Last Name
Emergency Contact Number *
Agree to NCE Terms & Conditions *

YES = Ride NO = NO Ride
Please Note: There must be one full paying adult to 1 x under 16. Entries will be rejected if this is not the case.

2nd Rider Form
Full Name

First Name Last Name
E-mail
Address

Street Address

Street Address Line 2

City / Town County

Postcode Country
Phone Number

Area Code Phone Number
Emergency Contact Name

First Name Last Name
Emergency Contact Number
Agree to NCE Terms & Conditions

YES = Ride NO = NO Ride Under 16 Rider (10 miles) Under 16 Rider (2 Loops Max)

3rd Rider Form
Full Name

First Name Last Name
E-mail
Address

Street Address

Street Address Line 2

City / Town County

Postcode Country
Phone Number

Area Code Phone Number
Emergency Contact Name

First Name Last Name
Emergency Contact Number
Agree to NCE Terms & Conditions

YES = Ride NO = NO Ride Under 16 Rider (10 miles) Under 16 Rider (2 Loops Max)

4th Rider Form
Full Name

First Name Last Name
E-mail
Address

Street Address

Street Address Line 2

City / Town County

Postcode Country
Phone Number

Area Code Phone Number
Emergency Contact Name

First Name Last Name
Emergency Contact Number
Agree to NCE Terms & Conditions

YES = Ride NO = NO Ride Under 16 Rider (10 miles) Under 16 Rider (2 Loops Max)

5th Rider Form
Full Name

First Name Last Name
E-mail
Address

Street Address

Street Address Line 2

City / Town County

Postcode Country
Phone Number

Area Code Phone Number
Emergency Contact Name

First Name Last Name
Emergency Contact Number
Agree to NCE Terms & Conditions

YES = Ride NO = NO Ride Under 16 Rider (10 miles) Under 16 Rider (2 Loops Max)

6th Rider Form
Full Name

First Name Last Name
E-mail
Address

Street Address

Street Address Line 2

City / Town County

Postcode Country
Phone Number

Area Code Phone Number
Emergency Contact Name

First Name Last Name
Emergency Contact Number
Agree to NCE Terms & Conditions

YES = Ride NO = NO Ride Under 16 Rider (10 miles) Under 16 Rider (2 Loops Max)
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Black Shuck Challenge Registration Form