Terrafirma / Reunert Cape Town Cycle Tour Entries 2018 Name* First Last Email* Enter Email Confirm Email ID Number / Passport Number* Nationality*South AfricaAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongoCosta RicaCôte d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayNorthern Mariana IslandsOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia and MontenegroSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabweDate of birth* 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 HealthWe 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 specifyDo 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 ShirtAS PART OF YOUR ENTRY, YOU WILL RECEIVE A STATE OF THE ART SABRINA LOVE CYCLING SHIRT. PLEASE INDICATE YOUR SIZE BELOWShirt or Top Size – +*XS - 50kgS - 60kgM - 70kgL - 80kgXL - 90kgXXL - 110kgXXXL - 120kg Δ
