CHARITY CYCLE RIDE – Wembley TO PLYMOUTH 22nd APRIL – 25th APRIL 2015 ENTRY FORM YOU WILL NEED TO RAISE A MINIMUM OF £300 IN SPONSORSHIP; IF YOU RAISE £1,000 YOU RECEIVE YOUR ENTRY FEE BACK! ENTRY FEE: £50 (includes: custom cycle shirt, accommodation and some meals) Entry forms available from www.argylecommunitytrust.co.uk, and Plymouth Argyle FC, Home Park. Please make cheques payable to Plymouth Argyle FITC Trust. CHARITIES TO BENEFIT: PROSTATE CANCER ARGYLE COMMUNITY TRUST PLYMOUTH ARGYLE FC YOUTH ACADEMY NAME: __________________________________________ ADDRESS: __________________________________________ __________________________________________ TELEPHONE: __________________________________________ MOBILE NO: __________________________________________ EMAIL: __________________________________________ DATE OF BIRTH: ________________________________________ EMERGENCY CONTACT NAME: ______________________________ EMERGENCY CONTACT NUMBER: ___________________________ P.T.O. THIS INFORMATION IS REQUIRED TO ENABLE US TO GROUP ENTRANTS ACCORDING TO ABILITY (PLEASE CIRCLE): HOW MANY TIMES DO YOU CYCLE EACH WEEK? 1 2 HOW MANY MILES DO YOU CYCLE EACH WEEK? 5 10 MORE THAN 3 MORE THAN 50 IF YOU CYCLE 10-15 MILES WHAT IS YOUR AVERAGE SPEED? ______________ ARE YOU A MEMBER OF A CYCLING CLUB? YES DO YOU COMPETE IN CYCLING EVENTS? ROAD RACES TIME TRIALS CYCLE CROSS MOUNTAIN BIKING SPORTIF WHAT STANDARD ARE YOU? NO NOVICE INTERMEDIATE COMPETENT ADVANCED WHAT TYPE OF BIKE WILL YOU BE RIDING? ROAD MOUNTAIN DO YOU REQUIRE ACCOMMODATION? YES NO DO YOU NEED TRANSPORTATION FOR YOUR BIKE? YES NO HAVE YOU ANY ALLERGIES? YES NO HYBRID IF YES PLEASE GIVE DETAILS: _______________ DO YOU HAVE ANY DIETARY NEEDS? YES NO IF YES PLEASE GIVE DETAILS: _______________ SHIRT SIZE: S(34/36) M(36/38) L(38/40) XL(40/42) XXL(42/44) By signing this form: 1. I certify that I am in good health and know of no medical reason why I may not participate in the WEMBLEY - PLYMOUTH cycle ride. I understand that the organisers have not undertaken any form of medical assessment or screening to evaluate my suitability for taking part and that I participate in the ride at my own risk. 2.I acknowledge that Argyle Community Trust, Plymouth Argyle FC or any of the sponsored charities will not be held responsible for any loss, accident or injury caused by me (whether to myself or to others) during the Oxford – Plymouth cycle ride and that I am responsible for my own safety equipment. I understand that I must wear a suitable cycling helmet when riding in this event. 3. I agree to follow the directions and instructions of the organisers, marshalls and police and follow the rules of the Highway Code and all relevant traffic laws. 4. I consent to the collection, storage and use of my personal information (including the medical information I have provided above) for the purposes of arranging the Oxford -Plymouth cycle ride in accordance with the Data Protection Act 1998. Personal data (including sensitive personal data) will not be passed to any third parties except in the case of medical emergency in which case this information may be passed to medical professionals to assist in the delivery of care to you. Medical information will be deleted or destroyed at the end of the cycle ride. [5. I consent to images of me taken during the cycle race being used for publicity purposes by the organisers or the sponsored charities] SIGNED: ____________________________________________________ DATE: ____________________________________________________ PLEASE RETURN THIS FORM (WITH ENTRY FEE) TO ARGYLE COMMUNITY TRUST, PLYMOUTH ARGYLE FC, HOME PARK, PLYMOUTH, PL2 3DQ OR E-MAIL COMPLETED FORM TO: [email protected]