1. Name
*
First Name
Last Name
2. Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
3. Email address
*
4. Mobile phone number
*
5. Organisation/Company
6. Date of birth
MM
DD
YYYY
7. Emergency contact name
*
8. Emergency contact number
*
9. Passport Number
*
10. Passport expiry date
*
11. Passport country of issue
*
12. Do you have any dietary requirements/food allergies?
*
Please Select
YES (Please provide details below)
NO
13. Do you have any non-food allergies and/or conditions?
*
Please select
YES (Please provide detail below)
NO
14. Do you have any recurring joint or back problems?
*
Please select
YES (Please provide details below)
NO
15. Do you have any medical conditions (Asthma, Epilepsy, Angina, High Blood Pressure etc)
*
Please select
YES (Please provide details below)
NO
16. Do you have any medial allergies? (Penicillin etc)
*
Please select
YES (Please list details below)
NO
17. Are you taking or require any medication?
*
Please select
YES (Please list details below)
NO
18. Is there anything else you wish to let us know?
*
Please select
YES (Please add detail below)
NO
19. Medical consent
*
21. Hotel Ibis, Dieppe - Night 1
*
Please select the type of room you would like
Single occupancy room (subject to availability and additional charges apply from £109)
Shared room (do not mind who i share with)
Shared room (please can I share with the person listed below)
22. City Hotel, Beauvais - Night 2
*
Please select the type of room you would like
Single occupancy room (subject to availability and additional charges apply from £109)
Shared room (do not mind who I share with)
Shared room (I would like to share with person listed below)
23. Ibis Hotel, Paris - Night 3
*
Please select the type of room you would like
Single occupancy room (subject to availability and additional charges apply from £179)
Shared room (do not mind who i share with)
Shared room (I would like to share with the person listed below)
25. I would like a bike challenge kit (4 x inner tubes, front & rear lights and a bell)
*
YES - Cost £49. We will be in touch.
NO
26. Would you like to rent a bike?
*
Please select
NO
YES - A member of our team will be in touch
27. The make, model and value of the bike you will be riding on the challenge?
*
29. My contact details
*
30. Insurance agreement (please check all boxes below)
*
31. GDPR Agreement (Privacy policy available below)
*
32. Terms & Conditions (available below)
*
