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. Company / Organisation
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
*
20. I would like to start my Hospices to Holland Cycle Challenge at...
*
St Wilfrid's Hospice, Eastbourne (approx 9am start)
St Michael's Hospice, St Leonards on Sea (appox 10.30 start)
21. Would you like to book a hotel room on the night before the challenge?
*
Please select
NO
YES - SINGLE ROOM - Additional charges apply (from £139)
YES - SHARED ROOM - Additional charges apply. Please specify below if you have someone you wish to share with (from £69.50)
22. Campanile Hotel, Dunkirk (18 September 2024)
*
Single occupancy room (subject to availability and additional charges apply from £99)
Shared twin room (do not mind who I share with)
Shared twin room (I would like to share with person listed below)
23. Fletcher Hotel, Renesse (19 September 2024)
*
Single occupancy room (subject to availability and additional charges apply from £149)
Shared twin room (do not mind who I share with)
Shared twin room (I would like to share with person listed below)
24. Ibis Hotel, Rotterdam (20 September 2024)
*
Single occupancy room (subject to availability and additional charges apply from £179)
Shared twin room (do not mind who i share with)
Shared twin room (please can I share with person listed below)
25. TBC Hotel, Amsterdam (21 September 2024)
*
Single occupancy room (subject to availability and additional charges apply from £189)
Shared twin room (do not mind who i share with)
Shared twin room (I would like to share with the person listed below)
26. I would like to return to London on the following Eurostar?
*
Please select date and time
Amsterdam to London - 22 September at 5pm (exact time TBC)
Other - Please add date/time below. Additional charges may apply.
27. If you have friends and/or family joining you in Amsterdam and they would like to join us for the celebratory meal (additional costs apply) please let us know how many below....
1
2
3
4
5
28. The make, model and value of the bike you will be riding on the challenge?
*
30. Insurance agreement (please check all boxes below)
*
31. GDPR Agreement (Privacy policy available below)
*
32. My consent
*
33. Terms & Conditions (available below)
*
34. I am happy for TFA Events to add me to the challenge WhatsApp group, using the number I entered above on this form. The group is the key way challenge information is shared.
*
