Registration Form 2014

HELMETS ARE MANDATORY NO HELMET, NO BIKE

Page 1 of 3
COUNTRY TEAM: SINGAPORE
A. PERSONAL DETAILS PLEASE ENTER YOUR NAME AS IS APPEARS ON YOUR PASSPORT
First Name Middle Name(s)
Family Name
Postal Address
Home Telephone Mobile (during ride)
mail
!po"en #anguage(s) Arabi$ nglish Fren$h %thers :
B. PASSPORT AND VISA DETAILS
&ate of birth (dd'mm'yyyy) !e( Female Male
Nationality Passport Number
Pla$e of )ssue Pla$e of *irth
&ate of )ssue &ate of (piry
Father+s Name Mother+s Name
,ity of -esiden$e ,ountry of residen$e
C. ROLE OF PARTICIPANT (check more than one box if applicable)
,y$list Me$hani$ Medi$ Media %ther. P#A! !P,)F/:
D. EMERGENCY CONTACT
Name
-elationship to you
mail
Telephone number(s)
E. BIKE INFORMATION
*i"e hire re0uired1
*i"e Frame si2e: 13'14'15 or 61 in$hes (for bi"e
allo$ation)
*rand and Model Number of bi"e (if bringing o7n)
* A must. for border $rossing
F. GENERAL INFORMATION
&o you ha8e any spe$ial dietary needs1
Please spe$ify e9g9 8egetarian
Registration Form 2014
HELMETS ARE MANDATORY NO HELMET, NO BIKE
Page 6 of 3
G. MEDICAL INFORMATION
*lood group if "no7n
Asthma1 )f yes. 7hat medi$ation do you ta"e1
High blood pressure1 )f yes. 7hat medi$ation do you ta"e1
Allergy1 )f yes. please spe$ify1
&iabetes1 )f yes. are you )nsulin dependent1
Pregnant1 /es No
pilepsy1 /es No
%n medi$al therapy at the
moment1
)f yes. please indi$ate the drug : the dose:
Any serious surgi$al
operation or in;ury1
)f yes. please indi$ate the drug : the dose:
H. FOLLOW THE WOMEN LEGAL WAIVER
Release ! L"a#"l"$% a&' Ass()*$"& ! all R"s+s
Please ,ea' -a,e!(ll%. $/"s "s a le0all% e&!,-ea#le 1a"2e, ! ,"0/$s.
ASSUMPTION OF RISKS
). <insert name= . a$"no7ledge that ) ha8e
8oluntarily applied to parti$ipate in Follo7 the >omen bi$y$le ride for pea$e in the Middle ast (?the ride@)9 )
am 8oluntarily parti$ipating in the ride 7ith "no7ledge that tra8el to the foreign $ountries on the ride+s route
in8ol8es numerous potential ris"s and dangers. in$luding but not limited to. a$ts of Aod. for$es of nature.
a$$ident or illness. e($ess physi$al e(ertion. or negligen$e (but not 7ilful or fraudulent $ondu$t) on the part of
Follo7 the >omen. and all sponsors and organi2ers of this e8ent9 ) hereby agree to be responsible for my
o7n 7elfare and a$$ept any and all ris"s of delay. unanti$ipated e8ents. illness. in;ury. emotional trauma or
death and 8ery this statement #% *la-"&0 )% "&"$"als /e,e.
RELEASE
) a$"no7ledge that my 8oluntary parti$ipation in the ride is based upon e(e$uting this -elease of #iability and
Assumption of all -is"s9 Therefore. as la7ful $onsideration for being permitted to parti$ipate on su$h trip. )
hereby release and dis$harge Follo7 the >omen. all sponsors and organi2ers of this e8ent. in$luding their
agents and employees from and against any and all liability arising from my parti$ipation in the ride9 ) agree
that this release shall be legally binding upon myself. my heirs. su$$essors. assigns and legal
representati8es. it being my intention to fully assume all the ris" of tra8el and to release Follo7 the >omen
and all sponsors and organi2ers from any and all liability to the ma(imum e(tent permitted by la79
KNOWING AND VOLUNTARY E3ECUTION
) ha8e $arefully read and fully understand the $ontents and legal ramifi$ations of this agreement9 ) understand
this is a legally binding and enfor$eable $ontra$t and sign it of my o7n free 7ill9 ) agree that if any portion of
this agreement is found to be 8oid or unenfor$eable. the remaining portions shall remain in full for$e and
effe$t9
!ignature
,ountry of parti$ipation
&ate
Registration Form 2014
HELMETS ARE MANDATORY NO HELMET, NO BIKE
Page 3 of 3
I. REASONS FOR PARTICIPATION
W/% a) I 4"&"&05
What are your reasons for applying to take part in Follow The Women?
W/a$ ' I e6*e-$5
What do you expect to achieve from taking part?
W/a$ ' I -))"$ $5
What do you feel you will contribute to Follow The Women?
H1 1"ll I *,)$e FTW5
What do you plan to do after the ride?
7. CERTIFICATION
) hereby $ertify that all the information on the abo8e pages is $orre$t. and ) ta"e all responsibility to ta"e part
in this e8ent 7ithout holding liable any of the organisers or sponsors in any of the four $ountries hosting this
e8ent9
Name
!ignature
&ate