Medical Certificate

To be filled by you, the participant:

First name: _______________________ Surname: _________________________

Address: _______________________________________________

Town: __________________________

County: __________________________ Country: ________________________

Tel: + (0) __________________ Mobile: + (0) ___________________

Contact Name: __________________________

Emergency Contact No: + (0) __________________________

To be filled by your GP/Doctor/Medical Practitioner:

I the undersigned, __________________________ Doctor of Medicine, see no reason that the above participant, on examination, cannot take part in competitive or non-competitive cycling over several days such as Poco Loco races.

Doctors Stamp Doctors Signature

Date: _____________________

This document is only valid for one year from the above date