Centre Mondial du Cyclisme



ATHLETE QUESTIONNAIRE PersonalSurname (as mentioned in the passport): FORMTEXT ?????First Name(s): FORMTEXT ?????Gender: ? Female ? MaleNationality: FORMTEXT ?????Date of Birth: FORMTEXT ?????Place of Birth: FORMTEXT ?????Languages Spoken: FORMTEXT ?????Home AddressStreet: FORMTEXT ?????Province: FORMTEXT ?????Postcode: FORMTEXT ?????Country: FORMTEXT ?????City: FORMTEXT ?????Phone NumbersHome: FORMTEXT ?????Email: FORMTEXT ?????Mobile: FORMTEXT ?????Emergency Contact: Relationship and Name: FORMTEXT ?????Email: FORMTEXT ?????Phone No: FORMTEXT ?????PassportImportant: Please send us a copy of your passport!Passport Number: FORMTEXT ?????Date of Issue: FORMTEXT ?????Valid Until: FORMTEXT ?????Is a VISA required to enter the Schengen States? ? Yes ? No Dietary Requirements / Known Allergies FORMTEXT ?????Medical Information – CONFIDENTIALAll information will be treated confidentially. This information is necessary to ensure the athletes health. Surname: FORMTEXT ?????First Name: FORMTEXT ?????Name of your doctor: FORMTEXT ????? Email: FORMTEXT ?????Current Injures: FORMTEXT ?????Illness: FORMTEXT ?????Current Treatment: FORMTEXT ?????What medication do you take now? FORMTEXT ?????Do you have any MAJOR Past injuries/Operations/Accidents? FORMTEXT ?????Please note all medical information that would be helpful? FORMTEXT ?????Sporting DetailsNational Federation: FORMTEXT ?????Team or Club: FORMTEXT ?????Discipline: FORMTEXT ?????Federation’s technical supervisor or National Coach:Please indicate surname, first name, complete address, phone and email: FORMTEXT ?????Results2019International EventResultDiscipline FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????National EventResultDiscipline FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Objectives2020 FORMTEXT ?????2021 FORMTEXT ?????Motivation QuestionsPlease write a short paragraph outlining your motivation explaining WHY you would like to come train with us at the World Cycling Centre? FORMTEXT ?????Place and Date:Signature: ................
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