1:1 learn to ride sessions - Brookfield Community School, Southampton - Tues 4th, 11th or 18th August 2026

First name of participant

Surname of participant

Gender of participant Male Female Prefer to self describe Prefer not to say

DOB of participant

Current year group at school

Current school attending

My child needs to borrow a bike Yes No

My child needs to borrow a helmet Yes No

What are you hoping that the participant will achieve during their Learn to Ride session?

I give permission for adjustments to be made to the helmet and/or cycle when considered necessary Yes No

Provide details of next of kin and/or emergency contact. Contact must be available for the duration of the session. Provide name, relationship to participant and address

Provide next of kin and/or emergency contact number for duration of session

Provide details of participants GP – name, address and telephone number

Provide details of any medical, mental ill-health and/or current injuries or illnesses/ on-going illnesses which could currently impact the participant in our care during the activity. To include but not limited to asthma, epilepsy, diabetes

Provide details of any significant allergies that may require medication or medical intervention

If the participant requires any regular medication please provide details – name and dosage of medication and whether they need any support

Provide details of any reasonable adjustments or additional support to learning which will support your child’s ability to safely ride a cycle

Has the participant received vaccination against tetanus in the last ten years? Yes No

Provide details of any medical advice to follow in emergencies

I have read the product details and confirm I understand my child’s name and my email address will be uploaded onto The Bikeability Trust’s Link System Yes No

I confirm the participant is in suitable health, and I consider them to be capable of taking part in the cycling course. In the event of illness or accident, I consent to any necessary medical treatment, which might include the use of anaesthetics. I accept that, the nature of cycling activities may involve some level of risk which cannot be fully eliminated even with competent instruction, and I consent to my child taking part. I confirm that in the event of any illness or medical treatment occurring after the return of this form and prior to the activity, I will inform bikeability.enquiries@hants.gov.uk or the instructor on the day of delivery Yes No

I confirm a parent/guardian or someone with caring responsibility will drop the participant off at the session and will handover information to the instructor. Please state how the participant will make their own way home after delivery Collected Making own way home

I confirm that all information provided is up to date and correct Yes No

Any other comments