Contact Information

Date of Birth*
Nationality*
Which Challenge Do You Want To Take On?*
  • 28th Jan - 3rd Feb 2019
Country
State / Province*
Address
City
Email*
Confirm Email*
Phone*

Emergency & Medical Information

Emergency Contact Name*
Emergency Contact Relationship*
Emergency Contact Number*
Please let us know about any relevant medical conditions, including any current medications that you're taking that we need to be aware of
Please let us know about any dietary requirements including allergens
  • Vegetarian
  • Coeliac
  • Nut allergy
  • Vegan
  • Halal
  • Kosher
  • Lactose Intolerant
  • Gluten Intolerant
  • Shellfish Allergy
  • Other
  • None
  • No Meat
  • No Fish
Are you travelling in a group?*
  • Yes
  • No
Do you have travel insurance?*
  • Yes
  • No
Are you happy to receive emails about the West Africa Cycle Challenge? *
  • Yes
  • No
Are you happy to receive emails from Street Child about our news, activities and appeals? You can unsubscribe at any time. *
  • Yes
  • No
There is a £100 deposit required to register for the West Africa Cycle Challenge. This will be deducted from your total package price. Please choose from one of the following payment options:*
  • Paypal
  • Cheque
  • Bank Transfer

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