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You can join us by either calling 01286 882391, or email club@energycycles.com or by letter to John Keightley (Secretary), 3 Fron Dirion, Nebo, Caernarfon, Gwynedd, LL54 6EN
Or print off and return the form below
Clwb Beicio Egni Energy Cycles Club
We are pleased to welcome you to our club. To ensure that we have the correct contact details for you, please insert the information requested below and return this form to:
John Keightley (Secretary), 3 Fron Dirion, Nebo, Caernarfon, Gwynedd, LL54 6EN
If you are under 16 please also ask a parent or carer to sign this form before it is returned. We will also use this information to ensure that you are kept informed about club events.
Personal Details of Individual
Name: Gender: Male □ Female □
Address:
Postcode:
Date of Birth: Email:
Telephone Home: Mobile:
Disability Information
The Disability Discrimination Act 1995 defines a disabled person as anyone with, ‘a physical or mental impairment, which has a substantial and long-term adverse effect on his or 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 □
Learning Disability □ Multiple Disability □
Other (please specify):
Cycling Information
Have you taken part in much cycling before? Yes □ No □
If yes, where have you taken part? (please indicate below)
Primary School □ Secondary School □
Local Authority Coaching Session(s) □ Club □
Other (please specify):
Medical Information
Please detail below any important medical information that our coaches/club should be aware
of (e.g. epilepsy, asthma, diabetes, a recent injury, etc).
Medical condition (s) and recommended treatment/actions to be taken if symptoms appear:
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 cycling activity sessions.
Emergency Contact Details (to be completed by parent/carer)
Please indicate below the person who should be contacted in case of an incident/accident
Contact Name: Relationship to Child:
Emergency Contact Numbers
Home: Mobile:
Notes
1. It is part of the British Cycling Code of Conduct to ensure that reasonable steps are taken to establish a safe environment where young people can enjoy developing their cycling skills.
2. Parents/carers are welcome to stay and watch the session but this is not compulsory.
3. Young people are expected to remain in the session from beginning to end unless they
have to leave early. If the young person 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 person’s responsibility to participate in cycling activities in a sporting manner.
5. Any young riders who persistently misbehave or put others in danger will be asked to leave the session.
6. It is the parent’s/carer’s responsibility to ensure that their child’s bike is in a safe condition to ride.
7. A correctly fitting cycling helmet must be worn at all times during the cycling activity sessions.
8. For all children under 12 years, coaching sessions will take place at a traffic-free facility.
Over 12s may be involved in coaching sessions that take place on the public highway. Young people are only invited to take part when the 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.
Please tick if you do not want your child to be involved in cycling activity sessions that take place on the public highways (See note 8 above). □
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 cycling activity sessions and
understand and agree that he/she participates in cycling activity sessions under the instruction of British Cycling qualified 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 responsibility for his/her own safety under the supervision of a British Cycling qualified coach. I confirm that he/she does not have any disability or medical condition (not disclosed overleaf) that could affect his/her ability to participate safely in cycling activity sessions.
• By returning this completed form, I agree to the child named above taking part in the
activities of the club
• I understand that I will be kept informed of these activities - for example timing and
transport details
• I understand that in the event of any injury or illness all reasonable steps will be taken to contact me, and to deal with that injury/illness appropriately
Name of Parent/Carer:
Signature of Parent/Carer: Date:
Once completed please return this form to:
John Keightley (Secretary), 3 Fron Dirion, Nebo, Caernarfon, Gwynedd, LL54 6EN
Emergency Contact Details (to be completed by parent/carer)
Please indicate below the person who should be contacted in case of an incident/accident
Contact Name: Relationship to Child:
Emergency Contact Numbers
Home: Mobile:
Notes
1. It is part of the British Cycling Code of Conduct to ensure that reasonable steps are taken to establish a safe environment where young people can enjoy developing their cycling skills.
2. Parents/carers are welcome to stay and watch the session but this is not compulsory.
3. Young people are expected to remain in the session from beginning to end unless they
have to leave early. If the young person 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 person’s responsibility to participate in cycling activities in a sporting manner.
5. Any young riders who persistently misbehave or put others in danger will be asked to leave the session.
6. It is the parent’s/carer’s responsibility to ensure that their child’s bike is in a safe condition to ride.
7. A correctly fitting cycling helmet must be worn at all times during the cycling activity sessions.
8. For all children under 12 years, coaching sessions will take place at a traffic-free facility.
Over 12s may be involved in coaching sessions that take place on the public highway. Young people are only invited to take part when the 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.
Please tick if you do not want your child to be involved in cycling activity sessions that take place on the public highways (See note 8 above). □
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 cycling activity sessions and
understand and agree that he/she participates in cycling activity sessions under the instruction of British Cycling qualified 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 responsibility for his/her own safety under the supervision of a British Cycling qualified coach. I confirm that he/she does not have any disability or medical condition (not disclosed overleaf) that could affect his/her ability to participate safely in cycling activity sessions.
• By returning this completed form, I agree to the child named above taking part in the
activities of the club
• I understand that I will be kept informed of these activities - for example timing and
transport details
• I understand that in the event of any injury or illness all reasonable steps will be taken to contact me, and to deal with that injury/illness appropriately
Name of Parent/Carer:
Signature of Parent/Carer: Date:
Once completed please return this form to:
John Keightley (Secretary), 3 Fron Dirion, Nebo, Caernarfon, Gwynedd, LL54 6EN
Emergency Contact Details (to be completed by parent/carer)
Please indicate below the person who should be contacted in case of an incident/accident
Contact Name: Relationship to Child:
Emergency Contact Numbers
Home: Mobile:
Notes
1. It is part of the British Cycling Code of Conduct to ensure that reasonable steps are taken to establish a safe environment where young people can enjoy developing their cycling skills.
2. Parents/carers are welcome to stay and watch the session but this is not compulsory.
3. Young people are expected to remain in the session from beginning to end unless they
have to leave early. If the young person 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 person’s responsibility to participate in cycling activities in a sporting manner.
5. Any young riders who persistently misbehave or put others in danger will be asked to leave the session.
6. It is the parent’s/carer’s responsibility to ensure that their child’s bike is in a safe condition to ride.
7. A correctly fitting cycling helmet must be worn at all times during the cycling activity sessions.
8. For all children under 12 years, coaching sessions will take place at a traffic-free facility.
Over 12s may be involved in coaching sessions that take place on the public highway. Young people are only invited to take part when the 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.
Please tick if you do not want your child to be involved in cycling activity sessions that take place on the public highways (See note 8 above). □
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 cycling activity sessions and
understand and agree that he/she participates in cycling activity sessions under the instruction of British Cycling qualified 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 responsibility for his/her own safety under the supervision of a British Cycling qualified coach. I confirm that he/she does not have any disability or medical condition (not disclosed overleaf) that could affect his/her ability to participate safely in cycling activity sessions.
• By returning this completed form, I agree to the child named above taking part in the
activities of the club
• I understand that I will be kept informed of these activities - for example timing and
transport details
• I understand that in the event of any injury or illness all reasonable steps will be taken to contact me, and to deal with that injury/illness appropriately
Name of Parent/Carer:
Signature of Parent/Carer: Date:
Once completed please return this form to:
John Keightley (Secretary), 3 Fron Dirion, Nebo, Caernarfon, Gwynedd, LL54 6EN
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