Personal Information

First Name:……………………………………………………………………………

Surname:………………………………………………………………………………

Address:………………………………………………………………………………

………………………………………………………………………………………….

Postcode……………………………………

Mobile Phone:………………………………………………………………………..

Email:…………………………………………………………………………………..

Date of Birth……………………………….

Gender: M / F

About You:

Have you done a Cycle challenge event before? Y / N

Please tell us about how much cycling you do at the moment:

…………………………………………………………………………………………

…………………………………………………………………………………………

Please indicate which level you rate yourself:

• Accomplished (avg 15mph)
• Intermediate (avg 12 mph)
• Recreational/leisure (less than 12 mph)

Are you part of a cycle club? Y / N

If so, what is the club name?………………………………………………………..

Are you a First Aider? Y / N

Where did you hear about the Super Cycle Challenge?

…………………………………………………………………………………………

Of the two charities, which if any, do you have a connection with?

• Halton Haven Hospice
• Mark Gorry Foundation

What is your reason for choosing this charity?

………………………………………………………………………………………….

• Please circle here if you prefer NOT to receive emails about Halton Haven Hospice.
• Please circle here if you prefer NOT to receive emails about the Mark Gorry Foundation.

Confirming Your Place

If you are successfully offered a place on the event a representative from your chosen charity will contact you on Monday 6^th February.

You will be required to pay the £75 deposit by Monday 13^th February. Please give it to your charity contact.

If you have not paid your deposit by this date you will forfeit your place and it will be offered to another person. The £75 deposit is non refundable and non transferable.

Fundraising Pledge

I confirm that I will raise the minimum fundraising target of at least £300 which will once received by the charities be equally split, as detailed on the event website and set out in the terms and conditions.
Please note that at least £100 of the above should be received by 20 April 2012 (6 weeks prior) to the challenge. The balance of all sponsorship/fundraising monies must be submitted no later than 29 June 2012 (4 weeks subsequent) to the challenge.

All fundraising should be given directly to your contact at either Halton Haven Hospice or the Mark Gorry Foundation, and you will be advised of how to do so within your fundraising pack.

Medical Declaration

This will be an intense challenge, you must have a high fitness level to participate.

I hereby declare that to the best of my knowledge there is nothing in my medical condition which could mean that there is a danger in me taking part in this event, and I will provide HHH and MGF with details of any previous or on-going medical conditions that could be relevant or could possibly be required as information in a medical emergency.

Please give details below of any medical conditions, that you believe we should be aware of:

………………………………………………………………………………………….

Signed………………………………………………………………………………….

Date………………………………………………

Please return this completed form to:

Tina Robinson

Halton Haven Hospice, Barnfield Avenue, Murdishaw, Runcorn, Cheshire, WA7 6HA