Sara Carrigan Cycling -Registration
Trinity Lutheran College
I would like to ...
Register as a new rider
Renew
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-- Participant Details
Full Name
*
First Name
Last Name
Gender
*
Male
Female
Mobile Number
*
E-mail
*
Date of Birth
*
-
dd
-
mm
yyyy
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Age
Emergency Contact Details
*
Name, Contact Number, Relationship
Address
Street Address
Street Address Line 2
Suburb
State
Post Code
What riding have you been doing lately?
Any health issues?
Any changes to Emergency Contact details?
Other notes
-- Exercise History & Cycling Experience
1. How often do you currently...
*
None
1x week
2x week
3x week
4x week
>4x week
Ride your bike?
Engage in non-cycling exercise?
2. How do you rate your current level of confidence about...
*
1 (Low)
2
3
4
5
6 (High)
Riding?
Riding in traffic?
3. How do you rate your current level of fitness?
*
1 (Low)
2
3
4
5
6 (High)
Fitness
4. What type of bike will you be riding during the program?
*
Road Bike (Skinny tyres, curly handlebars)
Hybrid (Flat bar, medium tyres)
Mountain Bike (Knobbly tyres)
Other
5. Do you have cycling shoes with cletes & 'clip-in' pedals?
*
No
Yes
6. Can you ride with one hand (for drinking, signalling etc)
*
No
Sort of
Yes
7. What is the longest ride you have done?
7. What do you wish to learn through this program?
8. What are your expectations of this program?
*
89. Any health issues?
*
10. Other notes
-- Declaration and Informed Consent
Terms and Conditions
*
I have read, understand and agree to the Terms & Conditions for participation in the Cycling Program (www.saracarrigan.com/TCs)
Participant Name
*
First Name
Last Name
Name of parent/legal guardian (if participant under 18)
I am authorised to accept Terms & Conditions as parent/legal guardian of Participant
Registration/Renewal Date
*
-
Day
-
Month
Year
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-- Payment
Select Payment Method
*
Debit/Credit Card
EFT
Purchase Sessions
*
$17 -1 Session
$75 -5 Sessions
$140 -10 Sessions
TOTAL: Amount Payable
My Cart
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TLC Cycling
$
Free
AUD
No. of Sessions
Please Select
1 Session ($17)
5 Sessions ($75)
10 Sessions ($140)
Item subtotal:
$
0.00
AUD
Total
$
0.00
AUD
Credit Card
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Please EFT Direct Deposit to:
Bank:
Commonwealth Bank
Ac Name:
Sara Carrigan Cycling Pty Ltd
BSB:
064 445
Ac No:
1046 7767
Note: Please use reference as "Surname TLC"
Send my Registration
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