JU:MP on a Bike Registration Form

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Please fill out the details of the person who is attending below

Email *

Participant's Full Name *

Ethnicity *

White British

British Pakistani

White Other

Other:

Phone number *

Home Postcode *

Select the area you live in *

Date of Birth *

YYYY

Current School (or college etc.)

Parent/Guardian name *

Parent/Guardian Phone Number *

Any Special Needs

Please let us know about anything such as medical conditions or disabilities which we might need to know about in order to make your time with us safe and pleasant.

Preferred Start Date of Course *

The course is in five week blocks. Every Saturday 1-3pm. Please check you can attend at least four of the five sessions before signing up.

CONSENT NOTICE

The information which you provide will only be used in the manner described in the attached privacy notice (https://goo.gl/C3mZMw). By Clicking Submit you consent to us using my personal data above, for the purpose of monitoring and evaluating the impact of the JU:MP project managed by Capital of Cycling.

I understand that this may involve us or someone nominated by us contacting me [by email] at a further date with a follow-up survey to assess the impact of the programme.

A copy of your responses will be emailed to the address you provided.

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