Zoë’s Place
Baby Hospice
A home from home for special babies
Easter Way, Ash Green, Coventry CV7 9JG
024 7636 1675 www.zoes-place.org.uk
Date:
Coventry to Paris Charity Bike Ride
Sponsored by
Thank you for your enquiry about this challenging, exciting, event which will commence on Thursday 11th September 2014.
Zoë’s Place Baby Hospices situated in Coventry, Liverpool and Middlesbrough provide baby-specific hospice care. Our hospices offer palliative, 24-hour respite, and end-of-life care for infants aged 0-5 years, with life-limiting and life-threatening conditions. It costs £25.00 to provide one hour of high quality nursing care for each baby. With little Government funding we rely heavily on fundraising events and the generosity of people in the community to raise the £1.3m we need every year to keep each hospice running.
Enclosed in this pack you will find your registration pack which has everything you need to know about the challenge ahead. We will be organising an information day and a training day(s) to help you on your way.
Once you have registered for the Coventry to Paris Charity Bike Ride you will become a member of Trek Bicycle Coventry Cycling Club; a leaflet is enclosed. Briefly, the membership offers discount on parts, clothing and accessories, regular training rides suitable for all abilities. Trek Bicycle Coventry is situated in the Leakes Store, Gallagher Business Park, Coventry, CV6 6PA, and we strongly recommend that you visit the store and ask the qualified staff about bike fit, nutrition and clothing. They have a wide range of bikes and equipment too!
We can help you to design your own fundraising plan, provide you with fundraising ideas and give you the support and encouragement you need in order to raise the minimum sponsorship level of £1,499.00.
All you have to do now read the information, then fill in your registration form and send it to us together with your registration fee of £99.00, payable to Zoë's Place Trust. There are limited places, so don’t delay.
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I do hope you will be able to take part in this fantastic fundraising event. If I may be of any assistance please do not hesitate to contact me on 024 7636 1675 or e-mail .
I’ll be in touch soon to check our starter pack arrived safely and that you have everything you need to sign up for this challenge of a lifetime.
Yours sincerely
Michael McCann
Fundraising Manager
COVENTRY TO PARIS CHARITY BIKE RIDE
11th-15th September 2014
Sponsored by
REGISTRATION FORM
Please read and complete all sections of the Registration and Medical Forms and return with your registration fee of £99 to:
Coventry to Paris Charity Bike RideZoë’s Place Baby Hospice
Easter Way
Ash Green
COVENTRY
CV7 9GJ / CHECKLIST
Please make sure you have enclosed the following:
1) Signed and completed Registration Form;
2) Signed and completed Medical Form (including GP signature if you have a medical condition or you are aged 65+);
3) Registration fee of £99 made payable to Zoë’s Place Trust;
4) Your completed form.
Please write clearly in capital letters.
WHICH ZOË’S PLACE HOSPICE DO WISH TO SUPPORT (Delete appropriately) Coventry, Liverpool or Middlesbrough)
______
PERSONAL DETAILS
Title as on passport (Mr/Mrs/Ms/Miss/other)______
Forenames as on passport ______Surname as on passport ______
Name you prefer to be addressed as ______
Address ______
Postcode______Occupation ______
Daytime phone______Evening telephone______
Email______T-SHIRT SIZE: S M L XL
Date of Birth ______Place of Birth ______
Marital Status ______Nationality______
PASSPORT DETAILS
Passport No. ______Country of Issue ______
Issue date ______Expiry date* ______
*Your passport must have at least six months to run from the date you return to the UK
SPECIAL REQUIREMENTS
Do you have any special dietary requirements/food allergies?
ÿ Vegetarian ÿ Vegan ÿ No Fish Those with other dietary requirements should bring supplementary food
ACCOMMODATION
If there is anyone you would like to share with please write their full name here (otherwise participants will be allocated rooms on same sex sharing basis – rooms will be twins / triples/quads). We will try to accommodate your request, however it cannot be guaranteed. Please note, married couples will not automatically be able to share.
Name(s)
WOULD YOU LIKE US TO SEND DETAILS TO A FRIEND?
Name ______
Address
Postcode ______Email ______
Daytime phone ______Evening phone ______
Where did you hear of this event? ______
Have you taken part in an overseas challenge before? ______
Would you like to be added to a contact sheet to be distributed to fellow participants? Yes / No
DECLARATION
I apply to take part in the COVENTRY TO PARIS CHARITY BIKE RIDE 2014, and abide by the Conditions of Entry and Booking Conditions.
I confirm that to the best of my knowledge my general state of health and fitness is good and I take full responsibility for my fitness to take part. I enclose a cheque for the registration fee of £99 made payable to Zoë’s Place Trust and a completed medical form.
Signature Name (capital letters) Date
______/___/___
MEDICAL FORM
Coventry to Paris Bike Ride
INTRODUCTION
This form must be completed by all applicants at the point you register for the challenge. Your place is not booked until a completed medical form has been submitted and approved.
The form contents will be treated as strictly confidential. Please take time to read this form carefully.
Charity events: This challenge will entail consecutive days of cycling and will be physically demanding. Due to the nature of this event some parts of the route may be away from main cities and hospitals. However, there will be trained medical personnel on hand and first aid supplies.
Fitness: The event in which you will be participating is challenging and requires a good level of fitness, strength and endurance. It is your responsibility to ensure that you have the appropriate level of fitness. The event is not recommended for those with any infirmity. You should check with your doctor to ensure that you are sufficiently fit and healthy to participate particularly if you have not undertaken regular exercise for some time or you are aged over 65 years.
Health: We ask you to provide a full and honest history of your medical history which will be passed to the event organiser and/or Zoë's Place Trust medical advisor so that he or she can be fully prepared during the challenge and advise us on your suitability for the event. Zoë's Place Trust or any third party organiser cannot accept any responsibility in the event that you do not disclose all relevant details. We encourage and support people to take part in our events but we reserve the right to refuse your application to take part in this event if recommended to do so by our doctor or medical advisor.
Undisclosed conditions: We need to know your health details – if you don’t tell us vital information, this could you put you and the group at risk.
Medical support before you go: Should you wish to speak to the organiser/trip doctor accompanying this challenge or the Zoë's Place Trust medical advisor, please ask us for the contact details.
Medical support during the challenge: We take your safety seriously and trained volunteer medical personnel provide first aid. They will advise on management of illness and injury including possible transfer to the best available local health facility and if necessary evacuation to the UK. You are responsible for managing your personal health conditions, and we ask you to bring sufficient supplies of your medication and notify the organiser if you require any special storage for medication.
Insurance: You must also declare all pre-existing conditions to your travel insurers otherwise they could deny any liability for any treatment or repatriation costs should you be taken ill on the challenge.
KEEP US INFORMED! FOR YOUR OWN SAFETY AND THE SAFETY OF THE GROUP
Should any of your medical details change after you have submitted this form, please inform
Zoë's Place Trust immediately. You may be asked to complete a new medical form. This will be reassessed by our medical team.
You may wish to talk to a Zoë's Place Trust or trip doctor (if applicable) in confidence. This service is available on request.
Contact us for details.
EVENT & PERSONAL DETAILS
Name of charity: ……………………………Date & destination of event: ……………………………………….
Title (Mr/Mrs/Miss/Ms/Dr): ……. Forenames:…………………… Surname: ………………………… Date of Birth: …………. Age: …………..
Nationality:………………………… Address : ………………………………..………………………………………………………………Postcode ………………………
Tel. (Day): …..………………Tel. (Eve): ………………….. Email: ……………..………………………………………………………………………………………………….
MEDICAL DETAILS
Height: …… (metres) Weight: ……… (kg) Blood group (if rare): ………
Allergies: Nuts / Penicillin / Gluten / Wasp or Bee stings / Shellfish / Hay fever /Other ......
Hospital operations & procedures scheduled 12 months prior to the challenge: …………………………………………………………………….
Any previous operations ……………………………………………………………………………………………………………………………………………………………….
If you tick YES to any of the conditions below, give full details and ask your GP to sign overleaf. Please give full details of any condition/s, use a separate sheet if required & sign it. You may ask your GP or consultant to provide a supporting letter.
Please tick Yes or No / Y / N / Please tick Yes or No / Y / NHeart disease or circulation problems / Haematological or blood disorders
Raised blood pressure / Joint or back injuries or problems
Chest or Lung disease / Epilepsy or seizures
Asthma / Diabetes - if yes is it Type 1 or Type 2
Heat or cold related illness / Thyroid or hormonal problems
Digestive or bowel disorders / Circulation problems
Cerebral disease such as stroke, head injury, tumour / Blood clots, deep vein thrombosis, pulmonary embolism
Previous history of altitude sickness / Fear of heights
Have you ever had any psychological or psychiatric illness, including eating disorders, deliberate self harm, overdoses, depression, anxiety, psychosis, alcoholism, drug dependency? / Do you have any objections to treatment, including blood transfusions and immunisations?
Do you have sight or hearing problems?
Details of your condition above or any other condition not listed
Please list all your current medication (Please bring supplies for the length of the trip plus spares)
NEXT OF KIN (This person is usually a blood relative or spouse and should not be on the event with you)
Name (in full):…………………………………………… Relationship: …………………………………………….. Email:…………………………………………..……
Address: ……………………………………………………………… Postcode: ………… Telephone: Day ………………..………. Eve ………………………….
DOCTOR’S DETAILS
The Zoë's Place Trust medical consultant, third party organiser or trip doctor (if apllicable) may wish to speak to your GP prior to your place being confirmed. Please provide your GP’s contact details below:
Doctor’s name: ……………………………………...……………………..Surgery telephone number:………………………………………………………
Surgery address: ………....………………………………...... Email address : ……………………………………………….
We reserve the right to ask you to provide a copy of the summary sheet from your GP records at your own expense (there is a standard NHS charge for this) if one of our trip doctors or our medical advisor considers it necessary.
PARTICIPANT DECLARATION
þ I understand this challenge is physically challenging.
þ I understand the need for fitness, have read the training guidelines & commit to a training program for the event.
þ To the best of my knowledge this is a true and accurate description of my medical history and current condition.
þ I sign below for Zoë's Place Trust to release this information to the doctor accompanying the event (if applicable) or to the third party organiser medical advisor to allow him/her to contact my GP.
þ In the event of illness or an accident on the trip I hereby give my permission for Zoë's Place Trust or third party organisers medical staff to initiate medical treatment & notify my next of kin in case of hospitalisation.
þ I am responsible for organising my own vaccinations, medication and will bring a personal first aid kit.
þ I will advise my insurer of my medical condition. Should I fail to do this, I understand that I will be liable for any medical costs incurred as a result of my condition,
Signed: …………………………………………... Date: …………………………
DOCTOR DECLARATION
If you are aged 65 or over or you have a pre-existing medical condition or you have received hospital treatment within 12 months of departure, you must ask your doctor to sign below. Before you are accepted on the challenge, your application may be assessed by the trip doctor (if applicable) or Zoë's Place Trust or third party organisers medical advisor for further consideration prior to your place being accepted.
When you visit your doctor to discuss the challenge, please take a copy of the itinerary with you.
EVENT DETAILS
Name of charity: Zoe’s Place Trust Date & destination of event: Coventry to Paris Bike Ride Sept 11th 2014
Type of activity: Cycling on road Number of activity days: 4 consecutive days
Distance (bike ride): Approx 8 Hours per day Altitude: (if over 2500m) N/A
PERSONAL DETAILS
Title (Mr/Mrs/Miss/Ms/Dr): ……. Forename/s: ………….………………………………………… Surname: ……………………………………
Date of Birth: ……………. Age: …………. Nationality: ………………………………..
Address: ……………………………………………………………………………………………………………… Postcode ……………………………………
Height:……(metres) Weight: ………(kg) BMI: ….. …. Blood group (if rare): ………………………………….
DOCTOR’S SIGNATURE
I confirm that I have read the itinerary my patient is planning to undertake and I know of no reason why this person should not participate in an event of this type at this point in time.
Doctor’s name: ………………………………………….. GP Practice stamp:
(Please use capitals)
Doctor’s signature: ………………………………………..
GMC Number: ……….…………………………………….
Date: …………………..………………………………….. ……
ZOË'S PLACE TRUST BOOKING CONDITIONS – COVENTRY TO PARIS BIKE RIDE
These are the terms and conditions of Zoë's Place Trust which apply to those who are advised by the charity or the trading company of the charity, known hereinafter as "the charity", that they will be participating in the fundraising event. Please refer to the charity’s own terms and conditions regarding your sponsorship and eligibility to travel. Only those potential participants who qualify under the charity’s rules will be entitled to travel. For those selected to travel, then the following conditions will apply: