Bikeability Training Consent Form Please complete the form either as the person registering to take part in Bikeability cycle training or as the parent or guardian of a child being registered to take part. Failure to complete this form will unfortunately result in you or your child being unable to take part in Bikeability cycle training. Question Title * 1. Name of Participant (please print full name) Question Title * 2. Date of birth Question Title * 3. Gender Male Female Prefer not to say Other (please specify) Question Title * 4. Ethnicity Asian - Bangladeshi Asian - Indian Asian - Chinese Asian - Pakistani Asian - Any other Asian background Black - Black African Black - Black Caribbean background Black - Any other Black background Mixed - White and Asian African Mixed - White and Black African Mixed - White and Black Caribbean background Mixed - Any other Mixed background White - Gypsy/Roma White - Irish White - Traveller of Irish Heritage White - White British White - Any other White background Any other ethnic group Any other ethnic group - Arab Prefer not to say Question Title * 5. Pupil Premium Eligible Yes No Prefer not to say Question Title * 6. Special Education Needs and Disability Yes No Prefer not to say Question Title * 7. Please specify if this would impact in taking part in the Bikeability Training below: * If one to one tuition is required, please contact us via bikeability@wearerise.co.uk to discuss the requirements further. Question Title * 8. Cycling Ability Cannot ride or use a balance bike Can use balance bike only Can pedal but with stabilizers Can pedal but lacking in confidence Can pedal but require further training in road safety Question Title * 9. Do you have access to a bicycle, e-cycle or adapted cycle at home? Yes No Prefer not to say If yes, please move to question 9. Question Title * 10. Do you have access to a bicycle, e-cycle or adapted cycle through other means? Yes No Prefer not to say If yes, please move to question 10. Question Title * 11. On average, how often would you say that you currently cycle? 5 or more days a week 3 or 4 days a week 1 or 2 days a week Once or twice a month Less than once a month Never Question Title * 12. How confident or unconfident do you feel cycling on roads in your local area? Very confident Fairly confident Not very confident Not confident at all Unsure / don’t know Question Title * 13. Please explain the reasons why you feel confident / unconfident when cycling on the road: Question Title * 14. How safe or unsafe do you feel cycling on roads in your local area? Very safe Safe Not very safe Not safe at all Unsure / don’t know Question Title * 15. Please explain the reasons why you feel safe / unsafe when cycling on the road: Question Title * 16. Please confirm if you have attended a previous session: Yes No If yes, please confirm which type of session attended: Question Title * 17. Are there any medical conditions which may impact on the ability to take part in this session: Yes No If yes, please provide details below and if any medication is required, please bring this to the session: During the session, your child may be photographed or recorded on video, and this material may be used by Rise for promotional purposes such as flyers, videos, and websites as part of the Bikeability project. For legal purposes your child’s name, address and date of birth will be held confidentially on file within the project. Question Title * 18. Parental consent form for the use of photographs of children. I give permission for photographs or videos to be taken of my child during Bikeability cycle training. I do not give permission for photographs or videos to be taken of my child during Bikeability cycle training. For further information regarding our data and privacy statements please e-mail: bikeability@wearerise.co.uk Question Title * 19. As far as I am aware I / my child has not been in contact with any infectious disease for the last three weeks and is in good health: Yes No Question Title * 20. In the event of my child being taken ill or injured during the period of the session to the extent that a surgical operation or serum injection becomes necessary, I authorise the leaders present to sign on my behalf any forms of consent which may be required by the medical authorities, provided that the delay required to obtain my own signature might be considered likely, in the opinion of the doctor or surgeon concerned, to endanger the health or safety of my child. Yes No Question Title * 21. I understand that during the session my child will be in the charge of the leaders present and under their instructions. I accept that my child may not be able to participate in the session if, in the opinion of the leaders in charge, they have behaved in a way that is unacceptable under normal circumstances. Yes No Question Title * 22. Electronic signature: Question Title * 23. Signed: Name Address Address 2 City/Town Post Code Email Address Phone Number Delivery of this cycle training is supported by the Department for Transport and subsidised by The Bikeability Trust. To support the equal delivery and monitoring of cycle training across England, the Bikeability Trust is required to collect information about rider characteristics. This data will enable to Trust to demonstrate the need for additional funding and target interventions to ensure every child can receive Bikeability cycle training.Please note that the personal details provided will be fully anonymised prior to data being provided to the Bikeability Trust. To view our Data Retention and Privacy Policies, please visit www.wearerise.co.uk/privacy-policy Done
