Terrafirma / Reunert Cape Town Cycle Tour Entries 2018

Name*
First Last
Email*
Enter Email Confirm Email
ID Number / Passport Number*
Nationality*
Date of birth*
Date Format: DD slash MM slash YYYY
Phone*
Address*
Street Address City State / Province / Region ZIP / Postal Code
Every Cyclist needs a compulsory timing chip*
- Yes - I already have a timing chip
- No - please purchase a timing chip for me
Every cyclist needs a timing chip which we will source and provide in your goodie bag before the race.
Please enter your timing chip number*
NOTE - without a valid timing chip you will not be able to participate in the race.
Next of kin name*
First Last
Next of kin cell phone number*
Relationship to entrant*
Do you have Medical Aid?*
- No
- Yes
Medical Aid Name and Number*
Main Member Name*
Personal Health
We are required by the Cycle Tour to provide detailed medical information this year as an entry requirement for each cyclist. Please be as honest as possible in order for you to receive the correct medical attention.
Height (cm)*
Weight (kg)*
Are you currently using any medication for the following conditions*
- None
- Arthritis
- Cancer
- Asthma or other lung problems
- Chronic pain
- Blood clotting disorder
- Depression/anxiety
- Blood pressure
- Diabetes
- Gastric disorders
- Stroke
- Heart conditions
- Thyroid disease
- HIV
- Other
- Other Psychiatric condition
Other medication...*
Other Psychiatric condition...*
Do you use any of the following medication?*
- No
- Cortisone
- Warfarin
Are you allergic to any of the following?*
- No
- Anti-inflammatories
- Nuts
- Bee sting
- Penicillin
- Elastoplast
- Sulphur
- Iodine
- Other
Other allergies...?*
Please specify
Do you have a known heart condition that limits your physical activity?*
- No
- Yes
Do you feel pain in your chest when doing physical activity?*
- No
- Yes
In the past month, have you had chest pains while you were NOT doing physical activity?*
- No
- Yes
Do you lose your balance through dizziness, especially while doing physical activity?*
- No
- Yes
Do you ever lose consciousness (e.g. fainting, sudden blackouts, seizures)?*
- No
- Yes
Are you on prescription drugs for your blood pressure or heart condition?*
- No
- Yes
Do you have a history of breathing or lung problems?*
- No
- Yes
Have you ever been told by a doctor that you have bone, joint or muscle problems that could be made worse by physical activity?*
- No
- Yes
Do you have diabetes or a thyroid condition?*
- No
- Yes
Do you have raised/high cholesterol?*
- No
- Yes
Is there a history of heart problems in immediate family (parents/siblings)?*
- No
- Yes
Do you have a diagnosed chronic illness or condition that could be made worse by physical activity?*
- No
- Yes
Do you know of any other reason why you should not do physical activity?*
- No
- Yes
Cycle Shirt
AS PART OF YOUR ENTRY, YOU WILL RECEIVE A STATE OF THE ART SABRINA LOVE CYCLING SHIRT. PLEASE INDICATE YOUR SIZE BELOW
Shirt or Top Size – +*

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PO BOX 1741, Plettenberg Bay, 6600, South Africa.

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