2023 USO Bike Ride Membership

2023 USO Bike Ride Membership

1st January to 31st December 2023
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Membership Options*

Individual$45Family $100Couple $80
Your Name: (Primary member)

First NameLast Name
Date of birth

MonthDayYear
Date
Partner/Spouse Name: (Couple/Family Membership Only)

First NameLast Name
Children's Names: (Family Membership Only)

Name:Age:
Children's Names: (Family Membership Only)

Name:Age:
Children's Names: (Family Membership Only)

Name:Age:
Address*

Street Address

Street Address Line 2

SuburbCity

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

Area CodePhone Number
Spouse Mobile Number:*

Area CodePhone Number
Home Number

Area CodePhone Number
Work Number

Area CodePhone Number
Signature*
Signature date
Ethnicity:

Primary Member - Please indicate below your ethnicity:
NZ MaoriSamoanCook Islands MaoriTonganNiueanTokelauanFijianNZ European/PakehaChineseIndianJapaneseKoreanOther ethnicity, please state:Other
Ethnicity:

Spouse/Partner ethnicity:
NZ MaoriSamoanCook Islands MaoriTonganNiueanTokelauanFijianNZ European/PakehaChineseIndianJapaneseKoreanOther ethnicity, please state:Other
EMERGENCY CONTACT DETAILS:

These details will be available to Lead Riders in case of an emergency. Please advise if you DO NOT wish this information to be shared.
Emergency Contact*

First NameLast Name
Phone Number*

Area CodePhone Number
Relationship to you*
I authorise USO Bike Ride to share this information in case of an emergency only*

YesNo
HEALTH INFORMATION

Primary Member:
Doctors Name

First NameLast Name
Address

Street Address

Street Address Line 2

SuburbCity

Postal / Zip CodeCountry
If 35+years, have you had a health check in the last 2 years?*

YesNo
Date of Last Dr's visit/Health Check
Briefly describe your/your spouses current exercise program*
Comments: eg: please advise of Spouse Health Conditions if applicable:
Tick the box that is relevant to you

History of heart problems, chest pain or strokeElevated Blood pressureAny chronic illness or conditionDifficulty with physical exerciseAdvice from physician not to exerciseSurgery in the last 12 monthsHistory of breathing or lung problemsMuscle, joint or back disorder, or any previous injury affecting youDiabetesHistory of heart problems in immediate familyOn regular Medication. If ticked; please advise below:Other
First Aid: Do you have a current first aid certificate?

YesNo
First Aid Certificate Expiry date
MEMBERSHIP PAYMENT
Individual $45Family $100Couple $80
Please deposit your USO Membership payment into the following USO Bike Ride Account:

USO Bike Ride BNZ

02-0700-0097632-00

Reference: Your surname
Should be Empty:

2023 USO Bike Ride Membership

Ethnicity:

Ethnicity:

EMERGENCY CONTACT DETAILS:

HEALTH INFORMATION

MEMBERSHIP PAYMENT