Hello Rider. I just need to get a little information from you in order to plan and book your ride. This form should take around 3 minutes to complete.
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Name *

(Full name as shown on passport)
 
Gender *


 
Date of birth

 
Your mobile number

 
Next of Kin Name

 
{{answer_22452029}}'s relationship to you

 
{{answer_22452029}}'s mobile number

 
Jersey size *


 
Cycling ability *


 
Dietary requirements

We will do our best to make sure everyone is catered for with what is available in the areas we are visiting in Ghana.
 
Is there anyone in the group you would like to room with? If so, please provide their name.

 
Would you like a single room? (£500 supplement) *

Due to very limited accomodation options, the supplement for single room is £500. If you chose yes, you will be contacted on completion of the form to arrange payment.
     
 
Please pay {{var_price}} for your single supplement

 
Please enter your Credit or Debit Card number:

 
The CVC number:

(3 or 4 digit security number on the back of your card)
 
The name on your card:

 
Your card's expiry month:


 
Your card's expiry year:


 
Please provide ALL relevant medical information (confidential)

Please provide information of any medical history, particularly injuries, that may affect your ability to cycle or that we should be aware of in your past. It's important to our dedicated ride nurse that you declare all relevant medical history here, no matter how small it may seem, better to be over-informed!
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