Cycling for Wellbeing Booking request Form Use this form to book a space on the Cycling for Wellbeing program. We will check the availability of spaces and get back to you with a full confirmation shortly.your detailsParticipant Full Name(Required) Participant Mobile Phone Number(Required) Participant Email address (or the person you are booking for) this will be used for the confirmation email(Required) Participant Postcode(Required) Which borough do you live in?(Required)-- Please Select --NewhamHackneyTower HamletsWaltham ForestKensington and ChelseaWestminstertimes and datesHiddenWhich is your first choice course to attend?(Required) Which is your first choice course to attend?(Required)Select...C4W-32 EAST LONDON _Olympic Park_Mondays & Wednesdays_1pm-3pm_ Starts Sept 6th - FOR LESS CONFIDENT RIDERSC4W-33 EAST LONDON _Olympic Park_Mondays & Wednesdays_1pm-3pm_ Starts Sept 20th - FOR MORE CONFIDENT RIDERSC4W-30 EAST LONDON_ Victoria Park_Mondays & Fridays 10-12pm_Starts Sept 13th - FOR LESS CONFIDENT RIDERSC4W-31 EAST LONDON_ Victoria Park_Mondays & Fridays 10-12pm_Starts Sept 27th - FOR MORE CONFIDENT RIDERSC4W-29 WEST LONDON_ Dalgarno Way Garage_Date and Time TBCWhich is your second choice course to attend?Select...C4W-32 EAST LONDON _Olympic Park_Mondays & Wednesdays_1pm-3pm_ Starts Sept 6th - FOR LESS CONFIDENT RIDERSC4W-33 EAST LONDON _Olympic Park_Mondays & Wednesdays_1pm-3pm_ Starts Sept 20th - FOR MORE CONFIDENT RIDERSC4W-30 EAST LONDON_ Victoria Park_Mondays & Fridays 10-12pm_Starts Sept 13th - FOR LESS CONFIDENT RIDERSC4W-31 EAST LONDON_ Victoria Park_Mondays & Fridays 10-12pm_Starts Sept 27th - FOR MORE CONFIDENT RIDERSC4W-29 WEST LONDON_ Dalgarno Way Garage_Date and Time TBCHiddenWhich is your second choice course to attend? your needsHow do you describe your cycling skills(Required) Cannot ride a 2 wheel bike without someone supporting me Can ride a 2 wheel bike on my own for at least 5 metres but am wobbly Can ride a 2 wheel bike no problem but would like to learn more Can ride a 2 wheel bike and am really confident Can ride another type of bike, or feel confident to try one Do you need to borrow a bike?(Required) Yes- I need a 2 wheeler Yes- I need another type of bike No- I have a roadworthy bike to use If you want to borrow a bike: How tall are you? If you have any medical or health issues (eg heart disease) or special needs please tell us here (confidential). Please state if you are Deaf/ Hard of hearing for the DeafPLUS course. Contact Name and Number for use in case of emergency during the sessions.(Required) monitoring informationHow did you hear about this program?(Required) Referral from GP/ Nurse/ Social Prescriber/ Community Connector or similar Referral from other professional e.g Occupational Therapist/ Counsellor or similar From someone or promotional material in my community From an external website or social media (eg council website) Can’t remember/ Don’t know/Other Was it one of these places?(Required)-- Please Select --ELFTEast Village/ E20Newham Social PrescriberNewham Link WorkerBromley By Bow Health practicesFamily Action_ ShoreditchOther/ can’t remember!Demographic information for Participant This does not affect your booking and is anonymised and used for monitoring purposes only. If booking on behalf of someone else answer to the best of your knowledge or select “Prefer not to say”.Age(Required)-- Please Select --18-2425-3435-4445-5455-6465+Prefer Not to SayGender(Required)-- Please Select --Non-binaryGender FluidFemaleTransgenderMaleOtherPrefer not to sayEthnicity(Required)-- Please Select --White: BritishWhite: IrishWhite: Any Other White BackgroundMixed Race: White & Black CaribbeanMixed Race: White & Black AfricanMixed Race: White & AsianMixed Race: Any Other Mixed BackgroundAsian/Asian British: IndianAsian/Asian British: PakistaniAsian/Asian British: BangladeshiAsian/Asian British: Any Other Asian BackgroundBlack/Black British: CaribbeanBlack/Black British: AfricanBlack/Black British: Any Other Black BackgroundChineseAny Other Ethnic GroupPrefer Not to SayDo you consider yourself to have a disability?(Required)-- Please Select --YesNoPrefer Not to Saynearly doneHave you read and do you agree to the terms and conditions of cycle training (you will not be able to proceed with participating unless you agree to the terms and conditions)(Required) Yes Terms and Conditions for Cycle Training activities By signing up for a cycle training with Bikeworks CIC [hereafter referred to as Bikeworks], The Participant or their Parent/Guardian [hereafter referred to as The Participant] is entering into an agreement between Bikeworks and The Participant which relates to all training run by Bikeworks on or after the date of signup. The Participant understands that: • The Participant accepts that the instructors may, at any time, refuse to continue to train them if their behaviour or ability level is deemed to be unsuitable. • The instructors may refuse to train The Participant if they deem their cycle to be not be roadworthy • It remains The Participants’ responsibility that they ride a roadworthy cycle and if they are in doubt as to whether a cycle is roadworthy they should seek the advice of a professional cycle mechanic. • It is the decision of The Participant whether to wear a cycle helmet and if it is one which The Participant provides, that is safe and suitable for use. The Participant understands that Bikeworks will not be held liable for any injury which is caused by the wearing of a helmet. • If The Participant chooses not to wear a cycle helmet on a training course, The Participant understands that Bikeworks will not be held liable for the result of any injury, which may have been prevented by the wearing of a helmet. • The Participant understands that Bikeworks CIC is not responsible for any injury or any loss or damage to any property which is not caused by an instructor’s negligence and that Bikeworks CIC takes no responsibility whatsoever for any injury or damage to any property which occurs either on the way to or from the lesson or subsequent to lessons. • The Participant understands that having taken training it does not necessarily follow that it is safe for them to ride a bicycle. To become a proficient cyclist takes much more practice than lessons of this kind can provide. • The Participant understands the personal details held by Bikeworks CIC may be passed on to the funding providers of this training and that they may contact them to ask for details of the lesson. Cycle training will be delivered in line with current Covid-19 government guidance. Participants must accept responsibility for the risk of transmission of Covid-19, notify Bikeworks of sanitiser allergies and identify vulnerable participants and participants living with vulnerable adults / children.
