Orchidcycle London To Paris

2nd – 5th September 2010 Application & Medical Form

 

Thank you for your interest in taking part in our OrchidCycle London to Paris 2100. To register you must pay a non-refundable (if accepted) entry fee of £100 to cover all non-travel costs. Please complete this application/medical form online.
Email
: events@orchid-cancer.org.uk

If you have any questions before completing this form please contact the Events Team on 020 7601 8259.

Personal Details

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Passport Details

Please note: You must have a ten year passport which must be valid for at least six months after the date of return to the UK from the ride. If you do not have a passport at the moment or your passport is due to expire before six months after the event please leave this blank and apply for a new passport as soon as possible in order to forward us your new details in good time before the event. There is no visa requirement for UK citizens. If you hold a non-British passport, please consult the French Consulate for advice.

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Emergency Contact Details

Please provide details of your next of kin (this must be someone who is not taking part in the ride with you).

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Dietary Requirements*

Please enter your dietary requirements.

Do you require vegetarian meals?

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T-Shirt Size *

Please enter your T-shirt Size.

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Why Orchid?

Please answer the above question.

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Employer Details

Please answer the above question.

Please answer the above question.

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Friends Sharing

Medical Information*

Cycling 250 miles in 3 days is a strenuous activity and the decision to take part should not be taken lightly. It is important you complete the medical declaration and without it we cannot guarantee your participation in this ride. All medical information will be treated with confidentiality and if you have any concerns that you would like to discuss before signing up for the ride please do not hesitate to contact us. Please complete the following by circling the appropriate answer. If you answer "Yes" to any of the following, we may require a note from your doctor stating that you are fit to go on the trip before you are permitted to participate in the event:

Heart trouble and/or blood pressure problems? NoYes Fracture / tendon / ligament / cartilage injury? NoYes
Back problems? NoYes Physical or other disability? NoYes
Diabetes? NoYes Mental or Psychiatric illness NoYes
Epilepsy or fainting? NoYes Hospitalisation in last 2 years? NoYes
Migraine? NoYes Are you suffering from/carrying any contagious diseases? NoYes
Severe head injury? NoYes Allergies? NoYes
Cancer? NoYes Registered as disabled? NoYes
Asthma / bronchitis / shortness of breath? NoYes Are you affected by any other serious illness? Including Parkinson’s Disease NoYes
Are you on any medication? If so what is it for and what is it? NoYes Are you pregnant or trying to get pregnant? NoYes
Photograph (optional)

Please make sure you upload either a JPEG, Bitmap or PNG image if you are submitting a photograph and make sure that the file size is under 3 MB.

Please make sure your photo matches the criteria above before submitting.

Referee

Please give details of one referee who is well known to you (e.g. your employer). We will only follow up your referee under certain circumstances and if deemed necessary.

Recommend a friend

If you would like details of this event sent to a friend or friends please complete their contact details. If you recommend more than 2 friends who also sign up for the event we can deduct £50 from your entry fee.

Conditions of entry
  • For OrchidCycle London to Paris we require you to pay a non-refundable (if accepted) registration fee of £100. You must commit to raising at least £1,200 for Orchid and you must pay in £700 of this before 24th June 2010. The remainder must be paid in before departure. If you are unable to meet these sponsorship requirements you will forfeit your place on the event. If you raise over £2,500 your £100 entry fee may be returned to you if you wish.
  • You must be at least 18 before the date of departure from the UK.
  • All funds raised for Orchid through your fundraising must be payable to Orchid. Should you, for whatever reason, not take up your place on the event all sponsorship forms and monies should be returned to Orchid or returned to your sponsors directly. Orchid can only refund your sponsors directly before we have paid out any costs for the event. In order to refund any sponsors you will need to provide their full contact details.
  • You must be covered by insurance for health, accident and loss. We strongly recommend you have travel insurance at the time we pay for the costs of the ride (i.e. 8 weeks before departure) to ensure you are fully covered for the ride in the event you have to pull out before departure.
  • I understand that failure to declare a medical problem may invalidate my health insurance All participants take part at their own risk. OrchidCycle London to Paris is a challenging ride and the decision to take part must not be taken lightly. You must commit to train hard for the event and follow any advice by our personnel on the ride. For health and safety reasons the tour operator and/or medical staff reserve the right to stop any participant from cycling
  • I consent to Orchid/Tall Stories contacting me via telephone, letter or email for any matter relating to my fundraising and my participation in this event.
  • I understand that wearing a cycle helmet whilst on the bike is compulsory and I will not be permitted to cycle without one.

Please agree to the terms and conditions

Insurance Details

Please ensure you have adequate travel insurance for the duration of the event. If you currently have a travel insurance policy that will be valid for the trip please fill out the details below as we need to have all your insurance details on file for the event. If you need to purchase insurance please ensure you pass these details on to us before the event.