Participant's Full Name:

Date of Birth:

Sex:
MaleFemale

Home Address:

Emergency contact details

Emergency Contact 1

Name:

Relationship to participant:

Contact number:

Emergency Contact 2

Name:

Relationship to participant:

Contact number:

Medical Information

Please provide any information required about medical conditions you feel we need to know about, e.g. Asthma or any allergies. If you have any concerns about your child participating in any form of physical activity then please consult your GP before giving permission for your child to take part in the Go-Ride activities.

Disability Information

The Equality Act 2010 defines a disabled person as anyone with a “physical or mental impairment which has a substantial and long term adverse effect upon his/her ability to carry out normal day to day activities”.

Do you consider that your child has a disability?
YesNoPrefer Not To Say

Consent

It is necessary to obtain consent for your child to take part in a Bolsover & District Cycling Club Go-Ride session during 2021 at venues deemed suitable for coaching purposes. If you wish for your son/daughter to participate, then please read the following information, complete the form and the parental consent notice.

All Go-Ride coaches are fully qualified British Cycling coaches that have received training in safeguarding and protecting children, and have been checked and cleared through the Disclosure and Barring Service. All fully qualified British Cycling coaches benefit from third party public liability and professional indemnity insurance cover.

Any information provided about your child will be securely and confidentially stored, processed and destroyed by Bolsover & District Cycling Club in accordance with the principles of the Data Protection Act. It will only be used for the purpose of contacting you or your child regarding future Go-Ride events or other club events where your child could get involved in cycling; or to provide you with information about British Cycling membership.

With your permission, Bolsover & District Cycling Club may also take photographs / video footage during the Go-Ride activity. These images may be used in coaching resources or placed on the Bolsover & District Cycling Club website or social media, or for general publicity purposes.

Are you happy for photographs / video footage to be taken and used as described?YesNo

Notes

Parents / guardians of children under the age of 13 years must remain on site during the sessions at all times. Parents of children over 13 years must be contactable at all times in the case of an emergency. It is the responsibility of the parent or guardian of children under the age of 13 years to escort their child to and from any toilet facilities provided.

A cycling helmet MUST be worn at all times during the activity. Bikes must be geared, have 2 working brakes and be mechanically sound and suitable for participation in the Go-Ride sessions. If a bike is deemed unsuitable your child will not be able to take part in the Go-Ride session. Any participants who persistently misbehave or put others in danger will be asked to leave the activity and will not be allowed to continue.

Parental Consent Notice

By submitting this form, I agree that:

• I have read the information contained in this form and declare that I have the right to give parental consent, and hereby consent to my child taking part in the Go-Ride activity.

• I confirm to the best of my knowledge that my child in my care does not suffer from any medical condition other than those detailed in this form.

I confirm that I have provided details of any relevant medical conditions that may affect my child taking part in the Go-Ride activity.

Parent / Carer Name:

Equality monitoring information

This data is confidential and information will be processed to enable effective monitoring to take place. Completion of this form is voluntary, however, the information provided will help us to monitor the effectiveness of our Equality Policy.

Religion

BuddhistChristianHinduJewishMuslimSikhUndisclosedNo religion

Ethnicity

White

BritishIrishGypsy/TravellerOther White (please state below)

Mixed

White & Black CaribbeanWhite & Black AfricanWhite & AsianOther Mixed (please state below)

Black or Black British

CaribbeanAfricanOther Black (please state below)

Other Ethnic Groups

ArabOther (please state below)

Prefer Not To Say

Prefer Not To Say

And finally...

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