Consent Form Contact details Email address of person completing the form (for any queries and copy.) * Name of rider in full: * M/F: * ---MaleFemale Date of birth (if no selector shows, enter as YYYY-MM-DD): * Main Emergency Contact Contact name: * Emergency Phone No:* MobileHomeWork Relationship to rider: * Alternative Contact Contact name: Emergency Phone No: MobileHomeWork Relationship to rider: Medical information Does the rider suffer from Asthma?* NoYes Please give brief details and any medication required: Does the rider have any medical conditions that require treatment?* NoYes Please give details and any medication required: Does the rider have any specific dietary requirements/allergy?* NoYes Please give details: Does the rider suffer from any other allergy e.g. medical? * NoYes Please give details: Consent* I am aware of Cheshire Maverick Cycling Club’s Welfare Policy. I acknowledge that the Club will only be liable in the event of any accident if they have failed to take reasonable steps in their duty of care towards riders during the activity. I confirm to the best of my knowledge that the rider does not suffer from any medical condition other than those detailed above and will inform the Club of any changes to the above. I am aware of the level of insurance for the Club ride and I will decide whether it is necessary to source personal insurance cover for myself/the rider. I understand that appropriate photographs/video images may be taken of during the course of the Club ride to document the event and promote Club activity and I consent to their use for these purposes only. I consent to the rider receiving medication as required and any emergency medical, dental or surgical treatment, including anaesthetic or blood transfusion, as considered necessary by the medical authorities present in the event that Emergency Contacts cannot be reached in time. For parents/carers only: I am aware of the nature of the Club ride(s) and consent to my child participating in the activity/activities. I agree to be at the drop-off/pick up point at the agreed time if I am not attending the ride myself. Rider/Parent/Carer signature (sign in box below with mouse/stylus): Typed Full Name: *Required field Please note that the form states that we have the right to use photographs/videos to document events and promote Club activity. Once any material is in the public domain, we cannot withdraw it or make other people stop using it. This means that although you withdraw this consent at any time by contacting the Club (see Contact Us on this website) for any future publications, any that were published with your consent may still be seen by other people.