Please use this form to register for the Afasic Bike Ride on the weekend 24-25 June 2017. Fill in all your details, choose a bike ride option and make your payment then click 'register now'. Your name* First Last Home address* Street Address Address Line 2 Town/City County Postcode Email address* Daytime phone number*Evening phone number*Mobile phone number*Age (at 24/06/2017)*If under 18 must be accompanied by a 'responsible adult'.Any dietary requirements*If you have no requirements, please type "none".Any allergies to medicine or food*If you have no allergies, please type "none".Any medical conditions we should be aware of*If you have no medical conditions, please type "none". Next of kin details in case of emergency during the event:Emergency contact (name)*Relationship*Emergency contact phone (daytime)*Emergency contact phone (evening)*Emergency contact phone (mobile)*Bike ride options (one day or two days)*Choose the full bike ride, Saturday 24 and Sunday 25 June or a one day ride on Saturday or Sunday.Full bike ride (Saturday and Sunday) - London to BathOne day ride (Saturday) - London to NewburyOne day ride (Sunday) - Newbury to BathPayment - full ride (please choose an option)*Payment options for the full bike ride (two days) including one night B&B accommodation.Pay £25 registration fee and raise a MINIMUM of £125 sponsorship per personPay £25 deposit and a further £80, 4 weeks before event, and raise what I canPayment - one day (please choose an option)*Payment options for one day (either Saturday or Sunday).Pay £15 registration and raise a MINIMUM of £60 sponsorshipPay £40 and raise what I canWhere did you hear about the Afasic Bike Ride?* Afasic website Facebook Twitter Newsletter Email Other Please tell us where you heard about this event* 'London to Bath' Charity Bike Ride - 24/25 June 2017 Terms & Conditions of Entry Terms and Conditions of Entry - Afasic London to Bath Bike Ride – 24/25 June 2017 (197.0 KiB, 167 hits)Acceptance of terms and conditions of entry*Please download and read the terms and conditions above. Yes, I confirm that I have read and understood the terms and conditions of the ride.