I being the parent/guardian of
____________________________________________
have read the information contained in this notice and hereby consent
to my child taking part in The
Surrey Rumble and understand and agree that my son/daughter
participates entirely at his/her own risk.
I have considered the nature of this event and have discussed it with
my son/daughter.
I also understand and agree that any child under the age of 16 will be
accompanied at all times by
the undersigned parent or guardian during the event.
Signed
(Parent/Guardian):______________________________Date:____________
PARTICIPANT'S DETAILS:
Name:________________________________ Date of
Birth:___________________
Club if any:__________________________________________________________
Address:____________________________________________________________
_________________________________Post Code:_________________________
British Cycling Membership No (if
applicable):________________________________
Home Tel:____________________ E-mail Address:_________________________
EMERGENCY CONTACT DETAILS:
Name:______________________________________________________________
Relationship to
Participant:______________________________________________
Contact Tel (inc. area
code):_____________________________________________
MEDICAL INFORMATION: (e.g. Asthma)
Please make a note below of any medical conditions you
feel we need to know about.
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 Surrey Rumble.
___________________________________________________________________
___________________________________________________________________
