PARTICIPANT REGISTRATION FORM
Please print clearly using BLOCK CAPITALS
Title
Full Name
Gender
Date of Birth
Address
County
Postcode
Preferred Contact Telephone Number
Home
Work
Mobile
Email
Emergency Contact Name
Emergency Contact Number
Ethnicity
Bangladeshi
(please tick one)
Black African
Black Caribbean
Chinese
Indian
Mixed Ethnicity
Other Asian
Other Black
Pakistani
White
Other
Prefer Not To Say
Would you describe yourself as having a disability?
Yes
Please give
No
details:
MEDICAL INFORMATION, CONFIRMATION & DECLARATION
If participant is under 16 years of age, this part of the form should be completed & signed by their parent/guardian.
If you are in any doubt as to your / your child's medical condition, you are strongly advised to consult your GP before
taking part in any form of exercise.
Are you currently on any medication or have any serious medical conditions?
Yes
No
Please give details:
Have you received any medical advice to the effect that you should not participate in aerobic activity or any
form of sport or exercise, or do you have any reason to believe that it would be prudent for you to refrain from
participating in aerobic activity or any form of sport or exercise?
Yes
No
Please give details:
I confirm that the information given on this form is complete and accurate and I agree that I / my child participate(s)
in activities offered by Eastlands Trust at my / their own risk in relation to any pre-existing medical condition. I
agree to inform Eastlands Trust immediately of any change in my / my child’s medical condition and agree for first
aid to be administered to me / my child if deemed necessary by qualified staff.
I understand the risks involved in cycle sports and other urban activities that take place at the HSBC UK National
Cycling Centre facilities. I appreciate that the venues accommodate international standard facilities which require
competency to ride a bike and may need the rider to ride at a lower speed than at other cycling facilities. I
acknowledge that a cycle helmet must be worn at all times whilst riding bikes, skateboards and scooters.
I also agree that no liability for negligence or otherwise shall attach to Eastlands Trust or any member of its staff in
respect of injury, loss or damage which I / my child may sustain. I understand that none of the confirmations given by
me or limitations or exclusions of liability in this questionnaire will apply to seek to exclude death or personal injury
caused by negligence of Eastlands Trust or anyone acting on its behalf.
If you object to supervised photographs being taken of you / your child for promotional activities, please tick
Signed
Date
Parent / Guardian Full Name (if applicable)
Data Protection
For the purposes of the Data Protection Act 1998, Eastlands Trust is the Data Controller of the information that you have provided on this form.
References to “we”, “us” and “our” are to Eastlands Trust. We may contact you with information concerning our services, or offers which may
be available to you, or to ask your opinion regarding our services, facilities and your experience. By signing this form, you consent to receiving
marketing communications by post, phone and email. If you do not wish to receive such communications, please tick the relevant box(es)
below to indicate which methods you do not wish to be contacted through.
Email
Phone
Post
Any of these
If you have any questions about your data, please email us at [email protected]
For Internal Purposes Only
Membership Type