2011 Nova Scotia HeartLand Tour Registration Form

If you are under 18 years old, please have your parent or guardian complete this form for you.

1) PARTICIPANT:

Name:

Phone:

E-mail:

Age -------- Under 18 18-25 26-32 33-39 40-46 47-53 54-60 Over 60      

2. PARENT OR GUARDIAN (if participant is under 18 years):

Parent / Guardian Name:

Relationship to participant:
Mother
Father
Legal Guardian

Parent / Guardian Phone:

Parent / Guardian E-mail:

3. Experience -------- Never cycled before Youth Rider Relaxed, Casual Rider up to 50km /week 50 to 120km / week 120 to 200km / week Over 200km / week     Type of Bike -------- Road Bike Mountain Bike

4. How did you hear about the HeartLand Tour?

5. Have you been treated / Are you currently being treated for any type of heart condition? yes no

If "yes", please explain:

6. Communities in which I (or my child) will be participating:

Halifax - July 9
Pictou County - July 10
Sydney - July 11
Antigonish - July 12
Truro - July 13
Bridgewater -July 15
Yarmouth - July 16
Valley - July 17