We are pleased to welcome
you to our club.
To ensure that we have the correct contact details for
you please insert the information below and return this form to the address
below, to our
Membership Secretary,
Please note if you are under 16 years of age you are requested to
ask for a Parent or Carer’s signature on the form over
We use this information to keep you up to date with our events. Your
details are not passed on to any other organisation.
Please Tick
Relevant category
Over
18yrs £20.00 o Under 18yrs £15.00 o (See note above)
Family
£25.00 o Student/ Retired/UB40 £15.00 o
Second
Claim £10.00 o Under 12yrs only
Free o
CTC Third
Party Insurance £12.00 o(Optional)(Per
Person)
Cheques
payable to:
Please print clearly
Full Name:______________________________________________Date
of Birth___/___/___Gender: M/F
Family Names (Family
Membership Only)
__________________________________________________
Date of Birth _____/_____/___Gender M/F
__________________________________________________
Date of Birth _____/_____/___Gender M/F
__________________________________________________
Date of Birth _____/_____/___Gender M/F
Full Address____________________________________________________________________________
______________________________________________________________________________________
________________________________________________________________Postcode_______________
Telephone (Home) (STD code____________)_____________________(
Email
Address_________________________________@________________________________________
If Second Claim, Give First Claim Club Details_________________________________________________
Please tick o if do not wish to receive the Ipswich Bicycle Club newsletter by email
Signature_______________________________________Date_______/________/________
Don’t forget you can earn your membership
fee back!
Marshalling & Other
Duties (Teas etc.) = 1 point, Time Keeping = 2 points, Organising Event =
6points.
1 point=£1 to be claimed
for club membership, Dinner etc. up to a limit of £12. Only one job counts per
event.
Aspect of the sport that you are interested
in_____________________________________
Notes
1 It is part of the British
Cycling Code of Conduct that reasonable steps are taken to establish a safe
environment where the young riders can enjoy developing their cycling skills.
2 Parents / Carers are quite
welcome to stay and watch the session, but this is not compulsory
3 Children are expected to
remain in the session from beginning to end unless they have to leave early. I
f the child has to leave early or is being collected by someone other than the
Parent / Carer, the Parent / Carer must advise the coach of the details of the
arrangement including who will be collecting the rider.
4 It is the young rider’s
responsibility to participate in cycling competitions in a sporting manner.
5 Any young riders who
persistently misbehave or put others at risk will be asked to leave the
session.
6 It is the parent’s
responsibility to ensure that their child’s bike is in a safe condition to
ride.
7 A correctly fitting,
approved cycling helmet must
be worn at all times during the coaching sessions.
8 For all children under
12yrs, coaching sessions will take place in a traffic free facility. However,
some children (over 12yrs only) may be involved in coaching sessions that take
place on the public highway. Children are only invited to take part when
coaches feel they are sufficiently responsible for their own actions and have
developed the necessary bike handling skills and fitness levels in order to
cope with riding on the public highways. If you do not wish your child to be
involved in these sessions then please tick the box below.
Please tick if you do
not want your child to be involved in coaching sessions
that take place on the public highway.
(see note 8 above)
Have you participated in any form of
cycling before:
Yes No
Primary School Secondary School Club Local Authority Coaching
Sessions
Other (please
specify)_________________________________________________________________________
Parental Consent
I, being the parent/carer of ____________________________have read the information contained on this form and hereby consent to him/her taking part in the coaching sessions and understand and agree that he/she participates in coaching sessions under instruction by British Cycling coaches entirely at his/her own risk. I have considered the nature of such sessions and have discussed them with him/her. I am satisfied that he/she is sufficiently responsible and competent to assume full and entire responsibly for his/her own safety under the supervision of a British Cycling coach. I confirm that he/she does not have disability or medical condition that could affect his/her ability to ride safely as a cyclist.
Medical Information
Please detail below any important medical information that our coaches/club should be aware of (e.g. epilepsy, asthma, diabetes,)
Medical condition(s) and recommended treatment/actions to be taken if symptoms occur
____________________________________________________________________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________
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 any coaching sessions.
Emergency contact details to be completed by parent/carer
Please indicate below the person that should be contacted in case of an incident/accident.
Contact Name___________________________________Relationship to child________________________________________
Emergency contact number: Home_________________________________Mobile_____________________________________
Disability information.
The Disability Discrimination Act 1995
defines a disabled person as anyone with ‘a physical or mental impairment,
which has substantial and long-term adverse effect on his/her ability to carry
out normal day to day activities’.
Do you consider yourself to have a disability?
Yes
No
If yes what is the nature of your disability?
Visual Impairment Hearing Impairment Physical Disability Multiple Disability
Learning Disability Other (please
specify)_________________________________________________________