2019 USO Bike Ride Membership

Address *

E-mail *
Spouse/Partner E-mail (Couple/Family Membership Only)
example@example.com
Mobile Number: *

- Area Code Phone Number
Spouse Mobile Number: *

- Area Code Phone Number
Home Number

- Area Code Phone Number
Work Number

- Area Code Phone Number
Signature *
Signature date
Ethnicity:

Primary Member - Please indicate below your ethnicity:
*

NZ Maori Samoan Cook Islands Maori Tongan Niuean Tokelauan Fijian NZ European/Pakeha Chinese Indian Japanese Korean Other ethnicity, please state:
Ethnicity:

Spouse/Partner ethnicity:
NZ Maori Samoan Cook Islands Maori Tongan Niuean Tokelauan Fijian NZ European/Pakeha Chinese Indian Japanese Korean Other ethnicity, please state:
EMERGENCY CONTACT
Emergency Contact *

First Name Last Name
Phone Number *

- Area Code Phone Number
Relationship to you *
HEALTH INFORMATION

Primary Member:
Doctors Name

First Name Last Name

Address

If 35+years, have you had a heart check? in the last 2 years *

Yes No
Date of Last Dr's visit/Health Check
Briefly describe your/your spouses current exercise program *
Tick the box that is relevant to you

History of heart problems, chest pain or stroke Elevated Blood pressure Any chronic illness or condition Difficulty with physical exercise Advice from physician not to exercise Surgery in the last 12 months History of breathing or lung problems Muscle, joint or back disorder, or any previous injury affecting you Diabetes History of heart problems in immediate family
Comments: eg: please advise of Spouse Health Conditions if applicable:
MEMBERSHIP PAYMENT
Individual membership *

Individual $45 Family $100 Couple $80
DIRECT CREDIT PAYMENT TO:

USO Bike Ride

BNZ 02-0700-0097632-02

PLEASE NOTE thIs bank a/c is for Membership Payments Only

Enter your SURNAME as your reference
Should be Empty:

Ethnicity: