Personal Details
First Name/s
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Surname
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Email
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Mobile
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ID/Passport No.
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Date of Birth
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Gender
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Select an option:
Male
Female
Address
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Country
Select your country:
Afghanistan
Åland Islands
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
British Virgin Islands
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo - Democratic Republic of
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equitorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Islas Malvinas)
Faroe Islands
Fiji
Finland
France
French Guyana
French Polynesia
French Southern and Antarctic Lands
Gabon
Gambia
Gaza Strip
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See (Vatican City)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia - Federated States of
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
North Korea
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russia
Rwanda
Saint Barthélemy
Saint Kitts and Nevis
Saint Lucia
Saint Martin (French Part)
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten (Dutch Part)
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia & South Sandwich Isl.
South Korea
South Sudan
Spain
Sri Lanka
St. Helena
St. Pierre and Miquelon
Sudan
Suriname
Svalbard
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
United States Minor Outlying Isl.
United States Virgin Islands
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Wallis and Futuna
West Bank
Western Sahara
Yemen
Zambia
Zimbabwe
European Union
Age
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Weight(kg)
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Height(cm)
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Cycling Jersey Size
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Cycling Jacket Size
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Choose Tour Parts you are entering
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Part 1 - Johannesburg to Kimberley
Part 2 - Kimberley to Cape Town
Part 1 & 2 - Johannesburg to Kimberley to Cape Town
Will you be doing the Cape Town Cycle Tour?
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Yes
No
Dietary Preference
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Select an option:
Normal
Vegetarian
Vegan
Halaal
Medical Details
Medical Aid (If Yes, please provide details)
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Select an option:
Yes
No
Name of Medical Aid (if applicable)
Medical Aid Number (if applicable)
1. Emergency Contact Name
*
Contact Number
*
2. Emergency Contact Name
*
Contact Number
*
Allergies/Other
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Entrants and participants in the Extreme Tour For Hunger Ride presented by Meals On Wheels Community Services (‘the event’) acknowledge that although all precaution have been taken by the organizing body to ensure the safety of all participants, there may be dangers inherent in participation in the Event and the activities related hereto.
Participants voluntarily assume the risk of attendance at and participation in the Event and hereby waive all claims of whatsoever nature and howsoever arising in relation to the Event or otherwise against any parties, including but not limited to the organizing body, the sponsors, the advertisers, any local authority and/or directors, employees, suppliers and assistants of these parties, including any individual Meals On Wheels Community Services Employees.
Due to the Covid-19 pandemic we must ensure all Government regulations and guidelines are being followed for everyone’s safety. Participants will be screened every morning before the start of the Event for each day. Sanitisers will be accessible and available throughout the duration of the Event. Participants will always be expected to wear a cloth face mask in all public places except when partaking in vigorous exercise. Participants are responsible for ensuring safe and healthy conduct, as well as reporting of any changes in their physical health during the Event.
Participants must report to the MOWCS Event Coordinator immediately if they present any of the observable symptoms associated with Covid-19 such as fever, cough, soar throat, shortness of breath or any of the following additional symptoms including body aches, loss of smell or taste, nausea, vomiting, diarrhoea, fatigue or weakness. Measures will be taken to isolate the Participant from the rest of the group and for the safety of others, alternative arrangements will be made as the Participant will no longer be able to partake in the remainder of the Event.
Participants voluntarily assume the risk of attendance at and participation in the Event and hereby waive all claims of whatsoever nature and howsoever arising in relation to the Event or otherwise against any parties, including but not limited to the organizing body, the sponsors, the advertisers, any local authority and/or directors, employees, suppliers and assistants of these parties, including any individual Meals On Wheels Community Services Employees.
Participants hereby irrevocably indemnify and hold harmless the parties against any liability and claims of any nature whatsoever and arising (whether directly or indirectly caused and whether inconvenience, accident, death, injury, illness to their person, theft or loss or damage to property or costs and expenses sustained, incurred or put to by Participants.
I HEREBY CONFIRM THAT I HAVE READ, UNDERSTAND AND ACCEPT THE EXTREME RIDE FOR HUNGER TOUR ENTRY FORM.
*
I grant permission to Meals on Wheels Community Services to use images taken of me.
Such use includes the display, distributions, publications, transmissions or otherwise use of photographs, images and/or videos taken for use in materials that include, but may not be limited to, printed materials such as Brochures, Newsletters, Videos and digital images used on Meals on Wheels Community Services Website and Social Media Pages, such as Facebook and for Meals on Wheels Community Services’ Fund-raising Events.
Declaration of consent
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Medical Questionnaire
Participants voluntarily assume the risk of attendance at and participation in the Event and hereby waive all claims of whatsoever nature and howsoever arising in relation to the Event or otherwise against any parties, including but not limited to the organizing body, the sponsors, the advertisers, any local authority and/or directors, employees, suppliers and assistants of these parties, including any individual Meals On Wheels Community Services Employees.
Participants hereby irrevocably indemnify and hold harmless the parties against any liability and claims of any nature whatsoever and arising (whether directly or indirectly caused and whether inconvenience, accident, death, injury, illness to their person, theft or loss or damage to property or costs and expenses sustained, incurred or put to by Participants.
1. Fitness Levels and Regular Exercise
Rate yourself on a scale of 1(least) to 10(most) as to how fit you think you are?
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Select an option:
1
2
3
4
5
6
7
8
9
10
In the last 12 months how often have you participated in some kind of exercise?
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Select an option:
5 or more times per week
3 to 4 times per week
1 to 2 times per week
1 to 2 times per month
Not at all
Do you currently have, or ever suffered from any of the following? (Tick only those that apply)
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Allergies
Heart problems
Breaks fractures dislocations
Anxiety or depression
Asthma shortness of breath
Epilepsy fits or seizures
Head injury migraines
Fainting loss of consciousness
An infectious tropical disease
Drug or alcohol abuse
Soft tissue nerve or joint injury
Low blood pressure
Blood or bleeding disorders
Diabetes metabolic condition
Panic attacks
Any physical or other disability
Recurrent infections
Surgery Operation
Gastric or eating problems
Skin conditions
Currently pregnant
None of the Above
Any other health related problems? If yes to any of the above, please give full details: include dates, nature of illness or injury, treatment, ongoing medical advice and any support needs.
Please list any regular medication or remedies you are taking and will be taking during the tour.
Please indicate if you are fit enough to maintain average speed of 32-36kph in the bunch for the duration of each stage.
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Yes I am fit enough.
No I am not, I will take a break if I am unable to keep up with the bunch.
Please Note:
Our friendly support staff will assist when you need a break at any time during each stage.
I have read and understood all the information contained in this document, and hereby confirm that all information I supplied are accurate and complete.
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In this document MOWCS refers to Meals on Wheels Community Services.
This is an agreement to comprehensively release MOWCS from arising claims out of participation in the Extreme Ride for Hunger Tour. Please communicate with MOWCS regards to any potential risks involved in the activity you signed up for. This form makes your assumption of risk complete.
In the event that I am rendered unconscious due to injury or illness, or if I am deemed unable to make sufficient judgement calls, I hereby authorise MOWCS Staff to act in my best interest and for my own personal safety. In consideration of the services I am to receive from MOWCS, I assume risks involved and release MOWCS from any claims, damages or liabilities that may arise out of these services as per our booking agreement.
I accept that in some instances MOWCS only act as coordinator of such activities such as transportation, accommodation and otherwise and hereby accept the terms and conditions set by these external service providers. I hereby accept these services will not hold MOWCS liable for any claims, damages, or liability that may arise out of these services.
If the schedule has to be delayed or altered in any way due to weather, trail, road or other conditions beyond the control of MOWCS, it is accepted that the responsible guide or agent for MOWCS will have the authority to make a judgement call in this regards. Any unexpected changes and issues arising from such delays or alterations is an assumed risk and MOWCS will not be held liable for any claims, damages or liability that may arise from such decision.
The MOWCS Event Coordinator on the tour retains the right to exclude any Cyclists/Staff from an activity (part or in full) if he/she deems it in the best interest of the individual or the rest of the group.
MOWCS are continually reviewing the protocols and safety measures for Covid-19 in line with the South African Government guidance and any changes or cancellations to this Event will be in made in the best interest of everyone’s safety and may happen without prior notice.
I have read and understood all the information contained in this document, and hereby confirm that all information I supplied are accurate and complete.
If any changes occur between submission of this form and your trip please share the details with us.
Cyclist Rules Agreement
Be On time – make sure to network on the WhatsApp group, your alarm etc.
Adhere to all traffic rules and regulations at all time.
At all times wear your helmet.
Ride in the same direction as flow of traffic.
Cycle as one group. No Cyclist will be allowed to ride off the front. It is not a race.
Weaker cyclist work less at the front, stronger cyclist on the other hand will work for longer periods at the front.
DO NOT LOOK BACK.
Do not overlap wheels.
Indicate if there is any objects in the road, potholes, bottles, bricks, stones etc.
If you have a problem fall to the back of the pack, raise your hand and the backup vehicle will assist you.
Come prepared with extra tubes and patching kit.
Eating and drinking etc, normally happens at the back of the pack.
Inappropriate behavior and foul language will not be tolerated, please communicate respectfully.
Assigned water points will be along the way +/- every 2 hours to refresh and refuel.
Approximately 15 minute breaks will be allocated at water points, starting when the last cyclist gets there.
Very important if you need any extra Medications/strapping/tubes/tyres, or anything that falls out of the tour, it will be available but on your own account - we will place it on a tab for you till the end of the tour.
Misuse of substances – alcohol, drugs or any illegal substance, will not be accepted.
If you are unable to keep up with the main group due to fatigue, injury or mechanical problem then you have to dismount and get into one of the support vehicles until such a time you are able to join the main group.
It is not compulsory to complete every stage of cycling each day. For your own safety, cycle only the sections within your physical limits and just enjoy the tour!
I agree to comply with ALL the rules of the Extreme Ride for Hunger Tour as outlined above. I do understand that if I do not adhere to the above mentioned rules then Meals on Wheels Community Services reserve the right to terminate my participation in the Extreme Ride for Hunger Tour and to send me home without re-reimbursement.
I hereby agree and accept the terms and conditions of the Cyclist rules as stated above.
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Are you able to follow instruction?
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Select an option:
Yes
No
Yes I can, but I can be stubborn sometimes.
Where did you hear about the Extreme Ride4Hunger? (Please tick applicable options)
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Instagram
Facebook
Youtube
Website search
Other (Please specify below)
Other
NB. Please Ensure you have read ALL Terms and Conditions, by ticking the accept boxes you hereby accept and agree to ALL terms and conditions
Any Additional Comments & Queries
*
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