ÿþ<html><head><META content="text/html; charset=ISO-8859-1" http-equiv=Content-Type> <script src="mouseover.js"> </script> <script src="subnavig.js"> </script> <script src="gen_subnavig.js"> </script> <!--meta_begin--> <title></title> <meta name="description" content=""> <meta name="keywords" content=""> <!--meta_end--></head> <BODY bgcolor="#FFFFFF" text="#000000" leftmargin="0" topmargin="0" marginwidth="0" marginheight="0"> <TABLE width="100%" border="0" cellspacing="0" cellpadding="0"> <TR> <TD align="left" valign="top" width="95%" background="img/base/ba51.gif"><img title="LEEDS MERCURY CYCLING CLUB" src="img/titles/mt.gif" width="600" height="44"><BR> <img title="A cycling club for all ages" src="img/titles/st.gif" width="600" height="28"></TD> <TD align="right" valign="top" width="5%"><IMG src="img/main/mi3_518.jpg" title="" width="180" height="72"></TD> </TR> </TABLE> <TABLE width="100%" border="0" cellspacing="0" cellpadding="0" height="77%"> <TR> <TD align="left" valign="top" width="5%" background="img/base/ba52.gif"> <P>&nbsp;</P><TABLE width="100%" border="0" cellspacing="0" cellpadding="0"> <TR> <TD align="left" valign="top" height="30"><A><IMG src="img/base/ba4.gif" width="134" height="22" name="home" border="0"></A></TD> </TR> <!--navig_begin--> <TR> <TD align="left" valign="top" height="30"><a href="index.html" onMouseOver="MM_swapImage('navig1','','img/navig/ngr1.gif',1)" onMouseOut="MM_swapImgRestore()"><IMG name="navig1" border="0" src="img/navig/ng1.gif" title="Home" width="134" height="22"></A></TD> </TR> <TR> <TD align="left" valign="top" height="30"><a href="2.html" onMouseOver="MM_swapImage('navig2','','img/navig/ngr2.gif',1)" onMouseOut="MM_swapImgRestore()"><IMG name="navig2" border="0" src="img/navig/ng2.gif" title="Events" width="134" height="22"></A></TD> </TR> <TR> <TD align="left" valign="top" height="30"><a href="3.html" onMouseOver="MM_swapImage('navig3','','img/navig/ngr3.gif',1)" onMouseOut="MM_swapImgRestore()"><IMG name="navig3" border="0" src="img/navig/ng3.gif" title="Training" width="134" height="22"></A></TD> </TR> <TR> <TD align="left" valign="top" height="30"><a href="4.html" onMouseOver="MM_swapImage('navig4','','img/navig/ngr4.gif',1)" onMouseOut="MM_swapImgRestore()"><IMG name="navig4" border="0" src="img/navig/ng4.gif" title="Results" width="134" height="22"></A></TD> </TR> <TR> <TD align="left" valign="top" height="30"><a href="5.html" onMouseOver="MM_swapImage('navig5','','img/navig/ngr5.gif',1)" onMouseOut="MM_swapImgRestore()"><IMG name="navig5" border="0" src="img/navig/ng5.gif" title="News" width="134" height="22"></A></TD> </TR> <TR> <TD align="left" valign="top" height="30"><a href="6.html" onMouseOver="MM_swapImage('navig6','','img/navig/ngr6.gif',1)" onMouseOut="MM_swapImgRestore()"><IMG name="navig6" border="0" src="img/navig/ng6.gif" title="GO RIDE" width="134" height="22"></A></TD> </TR> <TR> <TD align="left" valign="top" height="30"><a href="7.html" onMouseOver="MM_swapImage('navig7','','img/navig/ngr7.gif',1)" onMouseOut="MM_swapImgRestore()"><IMG name="navig7" border="0" src="img/navig/ng7.gif" title="Contact Us" width="134" height="22"></A></TD> </TR> <TR> <TD align="left" valign="top" height="30"><a href="8.html" onMouseOver="MM_swapImage('navig8','','img/navig/ngr8.gif',1)" onMouseOut="MM_swapImgRestore()"><IMG name="navig8" border="0" src="img/navig/ng8.gif" title="Photo Gallery" width="134" height="22"></A></TD> </TR> <TR> <TD align="left" valign="top" height="30"><a href="9.html" onMouseOver="MM_swapImage('navig9','','img/navig/ngr9.gif',1)" onMouseOut="MM_swapImgRestore()"><IMG name="navig9" border="0" src="img/navig/ng9.gif" title="Membership form" width="134" height="22"></A></TD> </TR> <TR> <TD align="left" valign="top" height="30"><a href="code_of_conduct_10.html" onMouseOver="MM_swapImage('navig10','','img/navig/ngr10.gif',1)" onMouseOut="MM_swapImgRestore()"><IMG name="navig10" border="0" src="img/navig/ng10.gif" title="Code of Conduct" width="134" height="22"></A></TD> </TR> <!--blog navigation start--> <script> </script> <script> function ngblog(){ } </script> <!--blog navigation end--> <!--navig_end--> <TR> <TD align="left" valign="top" height="30"><A><IMG src="img/base/ba5.gif" width="134" height="22" name="flash" border="0"></A></TD> </TR> </TABLE> </TD> <TD align="right" valign="top" width="95%"> <P> <!--email_begin--> <script src="ml.js"></script><font face="Arial" size="2" ><a href="#" style="color:000000" onclick="em_click() "><script>ml_write();</script> </a></font> <!--email_end--> &nbsp;&nbsp;&nbsp;</P> <TABLE width="90%" border="0" cellspacing="0" cellpadding="0" align="center"> <TR> <TD align="left" valign="top"> <P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-BoldCn"><SPAN style="FONT-SIZE: 11pt; FONT-FAMILY: Arial; mso-fareast-font-family: 'Times New Roman'; mso-bidi-font-family: 'Times New Roman'; mso-bidi-font-size: 12.0pt; mso-fareast-language: EN-US; mso-ansi-language: EN-GB; mso-bidi-language: AR-SA"><?xml:namespace prefix = v ns = "urn:schemas-microsoft-com:vml" /><v:shapetype id=_x0000_t75 coordsize="21600,21600" o:spt="75" o:preferrelative="t" path="m@4@5l@4@11@9@11@9@5xe" filled="f" stroked="f">&nbsp;</v:shapetype></SPAN></SPAN></P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><B><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-BoldCn">Club membership form<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /><o:p></o:p></SPAN></B></P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><B><SPAN style="FONT-SIZE: 14pt; COLOR: #0b0d58; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-BoldCn"><o:p>&nbsp;</o:p></SPAN></B></P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><?xml:namespace prefix = st1 ns = "urn:schemas-microsoft-com:office:smarttags" /><st1:place><B><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-BoldCn">Leeds</SPAN></B></st1:place><B><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-BoldCn"> Mercury Cycling Club<o:p></o:p></SPAN></B></P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><B><SPAN style="FONT-SIZE: 10pt; COLOR: #0b0d58; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-BoldCn; mso-bidi-font-size: 11.0pt"><o:p>&nbsp;</o:p></SPAN></B></P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><SPAN style="FONT-SIZE: 8pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-Roman; mso-bidi-font-size: 9.0pt">We are pleased to welcome you to our club. To ensure that we have the correct contact details for you, please insert the information requested below and return this form to:<o:p></o:p></SPAN></P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><SPAN style="FONT-SIZE: 8pt; COLOR: #0b0d58; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-Roman; mso-bidi-font-size: 9.0pt"><o:p>&nbsp;</o:p></SPAN></P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><B><SPAN style="FONT-SIZE: 8pt; COLOR: #0b0d58; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-BoldCn; mso-bidi-font-size: 9.0pt"><SPAN style="mso-spacerun: yes">&nbsp;</SPAN></SPAN></B><FONT face=Arial>Alistair Cameron, Treasurer, <st1:Street><st1:address>29 Knox Street, Rodley, Leeds, LS13 1LZ </st1:address></st1:Street>with the appropriate payment, cheques made payable to Leeds Mercury CC,&nbsp;thanks</FONT></P>&#10;<P>&#10;<TABLE class=MsoNormalTable style="BORDER-RIGHT: medium none; BORDER-TOP: medium none; MARGIN: auto auto auto 5.4pt; BORDER-LEFT: medium none; BORDER-BOTTOM: medium none; BORDER-COLLAPSE: collapse; mso-table-layout-alt: fixed; mso-border-alt: solid windowtext .5pt; mso-padding-alt: 0cm 5.4pt 0cm 5.4pt" cellSpacing=0 cellPadding=0 border=1>&#10;<TBODY>&#10;<TR style="mso-yfti-irow: 0">&#10;<TD style="BORDER-RIGHT: #d4d0c8; PADDING-RIGHT: 5.4pt; BORDER-TOP: #d4d0c8; PADDING-LEFT: 5.4pt; PADDING-BOTTOM: 0cm; BORDER-LEFT: #d4d0c8; WIDTH: 216pt; PADDING-TOP: 0cm; BORDER-BOTTOM: windowtext 1pt solid; BACKGROUND-COLOR: transparent; mso-border-bottom-alt: solid windowtext .5pt" vAlign=top width=288>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><SPAN style="FONT-SIZE: 8pt; COLOR: black; mso-bidi-font-size: 12.0pt; mso-fareast-language: EN-GB"><FONT face=Arial>Membership required<o:p></o:p></FONT></SPAN></P></TD>&#10;<TD style="BORDER-RIGHT: #d4d0c8; PADDING-RIGHT: 5.4pt; BORDER-TOP: #d4d0c8; PADDING-LEFT: 5.4pt; PADDING-BOTTOM: 0cm; BORDER-LEFT: #d4d0c8; WIDTH: 153pt; PADDING-TOP: 0cm; BORDER-BOTTOM: windowtext 1pt solid; BACKGROUND-COLOR: transparent; mso-border-bottom-alt: solid windowtext .5pt" vAlign=top width=204>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><SPAN style="FONT-SIZE: 12pt; COLOR: black; FONT-FAMILY: 'Times New Roman'; mso-fareast-language: EN-GB">&nbsp;</SPAN><SPAN style="FONT-SIZE: 8pt; COLOR: black; mso-bidi-font-size: 12.0pt; mso-fareast-language: EN-GB"><o:p></o:p></SPAN></P></TD>&#10;<TD style="BORDER-RIGHT: #d4d0c8; PADDING-RIGHT: 5.4pt; BORDER-TOP: #d4d0c8; PADDING-LEFT: 5.4pt; PADDING-BOTTOM: 0cm; BORDER-LEFT: #d4d0c8; WIDTH: 36pt; PADDING-TOP: 0cm; BORDER-BOTTOM: windowtext 1pt solid; BACKGROUND-COLOR: transparent; mso-border-bottom-alt: solid windowtext .5pt" vAlign=top width=48>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: center" align=center><B style="mso-bidi-font-weight: normal"><SPAN style="FONT-SIZE: 10pt; COLOR: black; FONT-FAMILY: Wingdings; mso-bidi-font-size: 12.0pt; mso-fareast-language: EN-GB; mso-ascii-font-family: Arial; mso-hansi-font-family: Arial; mso-char-type: symbol; mso-symbol-font-family: Wingdings"><SPAN style="mso-char-type: symbol; mso-symbol-font-family: Wingdings">&#252;</SPAN></SPAN></B><B style="mso-bidi-font-weight: normal"><SPAN style="FONT-SIZE: 10pt; COLOR: black; mso-bidi-font-size: 12.0pt; mso-fareast-language: EN-GB"><o:p></o:p></SPAN></B></P></TD></TR>&#10;<TR style="HEIGHT: 19.85pt; mso-yfti-irow: 1">&#10;<TD style="BORDER-RIGHT: windowtext 1pt solid; PADDING-RIGHT: 5.4pt; BORDER-TOP: #d4d0c8; PADDING-LEFT: 5.4pt; PADDING-BOTTOM: 0cm; BORDER-LEFT: windowtext 1pt solid; WIDTH: 216pt; PADDING-TOP: 0cm; BORDER-BOTTOM: windowtext 1pt solid; HEIGHT: 19.85pt; BACKGROUND-COLOR: transparent; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt" width=288>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><SPAN style="FONT-SIZE: 10pt; COLOR: black; mso-bidi-font-size: 12.0pt; mso-fareast-language: EN-GB"><FONT face=Arial>Juvenile/Junior (under 18) <o:p></o:p></FONT></SPAN></P></TD>&#10;<TD style="BORDER-RIGHT: windowtext 1pt solid; PADDING-RIGHT: 5.4pt; BORDER-TOP: #d4d0c8; PADDING-LEFT: 5.4pt; PADDING-BOTTOM: 0cm; BORDER-LEFT: #d4d0c8; WIDTH: 153pt; PADDING-TOP: 0cm; BORDER-BOTTOM: windowtext 1pt solid; HEIGHT: 19.85pt; BACKGROUND-COLOR: transparent; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt" width=204>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><SPAN style="FONT-SIZE: 10pt; COLOR: black; mso-bidi-font-size: 12.0pt; mso-fareast-language: EN-GB"><FONT face=Arial>&#163;5.00<o:p></o:p></FONT></SPAN></P></TD>&#10;<TD style="BORDER-RIGHT: windowtext 1pt solid; PADDING-RIGHT: 5.4pt; BORDER-TOP: #d4d0c8; PADDING-LEFT: 5.4pt; PADDING-BOTTOM: 0cm; BORDER-LEFT: #d4d0c8; WIDTH: 36pt; PADDING-TOP: 0cm; BORDER-BOTTOM: windowtext 1pt solid; HEIGHT: 19.85pt; BACKGROUND-COLOR: transparent; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt" width=48>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><SPAN style="FONT-SIZE: 12pt; COLOR: black; FONT-FAMILY: 'Times New Roman'; mso-fareast-language: EN-GB">&nbsp;</SPAN><SPAN style="FONT-SIZE: 10pt; COLOR: black; mso-bidi-font-size: 12.0pt; mso-fareast-language: EN-GB"><o:p></o:p></SPAN></P></TD></TR>&#10;<TR style="HEIGHT: 19.85pt; mso-yfti-irow: 2">&#10;<TD style="BORDER-RIGHT: windowtext 1pt solid; PADDING-RIGHT: 5.4pt; BORDER-TOP: #d4d0c8; PADDING-LEFT: 5.4pt; PADDING-BOTTOM: 0cm; BORDER-LEFT: windowtext 1pt solid; WIDTH: 216pt; PADDING-TOP: 0cm; BORDER-BOTTOM: windowtext 1pt solid; HEIGHT: 19.85pt; BACKGROUND-COLOR: transparent; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt" width=288>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><SPAN style="FONT-SIZE: 10pt; COLOR: black; mso-bidi-font-size: 12.0pt; mso-fareast-language: EN-GB"><FONT face=Arial>Senior (18 or over)<o:p></o:p></FONT></SPAN></P></TD>&#10;<TD style="BORDER-RIGHT: windowtext 1pt solid; PADDING-RIGHT: 5.4pt; BORDER-TOP: #d4d0c8; PADDING-LEFT: 5.4pt; PADDING-BOTTOM: 0cm; BORDER-LEFT: #d4d0c8; WIDTH: 153pt; PADDING-TOP: 0cm; BORDER-BOTTOM: windowtext 1pt solid; HEIGHT: 19.85pt; BACKGROUND-COLOR: transparent; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt" width=204>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><SPAN style="FONT-SIZE: 10pt; COLOR: black; mso-bidi-font-size: 12.0pt; mso-fareast-language: EN-GB"><FONT face=Arial>&#163;15.00<o:p></o:p></FONT></SPAN></P></TD>&#10;<TD style="BORDER-RIGHT: windowtext 1pt solid; PADDING-RIGHT: 5.4pt; BORDER-TOP: #d4d0c8; PADDING-LEFT: 5.4pt; PADDING-BOTTOM: 0cm; BORDER-LEFT: #d4d0c8; WIDTH: 36pt; PADDING-TOP: 0cm; BORDER-BOTTOM: windowtext 1pt solid; HEIGHT: 19.85pt; BACKGROUND-COLOR: transparent; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt" width=48>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><SPAN style="FONT-SIZE: 12pt; COLOR:£15.00<o:p></o:p></FONT></SPAN></P></TD>&#10;<TD style="BORDER-RIGHT: windowtext 1pt solid; PADDING-RIGHT: 5.4pt; BORDER-TOP: #d4d0c8; PADDING-LEFT: 5.4pt; PADDING-BOTTOM: 0cm; BORDER-LEFT: #d4d0c8; WIDTH: 36pt; PADDING-TOP: 0cm; BORDER-BOTTOM: windowtext 1pt solid; HEIGHT: 19.85pt; BACKGROUND-COLOR: transparent; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt" width=48>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><SPAN style="FONT-SIZE: 12pt; COLOR: black; FONT-FAMILY: 'Times New Roman'; mso-fareast-language: EN-GB"> &nbsp;</SPAN><SPAN style="FONT-SIZE: 10pt; COLOR: black; mso-bidi-font-size: 12.0pt; mso-fareast-language: EN-GB"><o:p></o:p></SPAN></P></TD></TR>&#10;<TR style="HEIGHT: 19.85pt; mso-yfti-irow: 3">&#10;<TD style="BORDER-RIGHT: windowtext 1pt solid; PADDING-RIGHT: 5.4pt; BORDER-TOP: #d4d0c8; PADDING-LEFT: 5.4pt; PADDING-BOTTOM: 0cm; BORDER-LEFT: windowtext 1pt solid; WIDTH: 216pt; PADDING-TOP: 0cm; BORDER-BOTTOM: windowtext 1pt solid; HEIGHT: 19.85pt; BACKGROUND-COLOR: transparent; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt" width=288>&#10; <p style="font-family: Arial, Helvetica, sans-serif; font-size: x-small"> Family (2 Snr. + all jnrs at same address)</p> </TD>&#10;<TD style="BORDER-RIGHT: windowtext 1pt solid; PADDING-RIGHT: 5.4pt; BORDER-TOP: #d4d0c8; PADDING-LEFT: 5.4pt; PADDING-BOTTOM: 0cm; BORDER-LEFT: #d4d0c8; WIDTH: 36pt; PADDING-TOP: 0cm; BORDER-BOTTOM: windowtext 1pt solid; HEIGHT: 19.85pt; BACKGROUND-COLOR: transparent; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt" width=48>&#10; <p style="font-family: Arial, Helvetica, sans-serif; font-size: x-small"> £20.00</p> </TD>&#10;<TD style="BORDER-RIGHT: windowtext 1pt solid; PADDING-RIGHT: 5.4pt; BORDER-TOP: #d4d0c8; PADDING-LEFT: 5.4pt; PADDING-BOTTOM: 0cm; BORDER-LEFT: #d4d0c8; WIDTH: 36pt; PADDING-TOP: 0cm; BORDER-BOTTOM: windowtext 1pt solid; HEIGHT: 19.85pt; BACKGROUND-COLOR: transparent; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt" width=48>&#10; &nbsp;</TD></TR>&#10;<TR style="HEIGHT: 19.85pt; mso-yfti-irow: 4; mso-yfti-lastrow: yes">&#10;<TD style="BORDER-RIGHT: windowtext 1pt solid; PADDING-RIGHT: 5.4pt; BORDER-TOP: #d4d0c8; PADDING-LEFT: 5.4pt; PADDING-BOTTOM: 0cm; BORDER-LEFT: windowtext 1pt solid; WIDTH: 216pt; PADDING-TOP: 0cm; BORDER-BOTTOM: windowtext 1pt solid; HEIGHT: 19.85pt; BACKGROUND-COLOR: transparent; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt" width=288>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><SPAN style="FONT-SIZE: 10pt; COLOR: black; mso-bidi-font-size: 12.0pt; mso-fareast-language: EN-GB"><FONT face=Arial> Second claim </TD>&#10; <TD style="padding: 0cm 5.4pt; border-right: 1pt solid windowtext; border-top: medium none #d4d0c8; border-left: medium none #d4d0c8; WIDTH: 36pt; BORDER-BOTTOM: windowtext 1pt solid; HEIGHT: 19.85pt; BACKGROUND-COLOR: transparent; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; font-family: Arial, Helvetica, sans-serif; font-size: x-small;" width=48>&#10; <p style="width: 200px"> £3.00 Juniors, £5.00 Seniors</p> </TD></TR></TBODY></TABLE></P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><o:p><FONT face=Arial>&nbsp;</FONT></o:p><SPAN style="FONT-SIZE: 8pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-Roman; mso-bidi-font-size: 9.0pt">If you are under 16 please also ask a parent or carer to sign this form before it is returned. We will also use this information to ensure that you are kept informed about club events.<o:p></o:p></SPAN></P>&#10;<P><SPAN style="FONT-FAMILY: Arial; mso-bidi-font-family: 'Times New Roman'"><B><SPAN style="FONT-SIZE: 8pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-BoldCn; mso-bidi-font-size: 9.0pt">Personal Details of Individual<o:p></o:p></SPAN></B></P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><SPAN style="FONT-SIZE: 8pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-Roman; mso-bidi-font-size: 9.0pt">Name: <SPAN style="mso-tab-count: 5">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </SPAN>Gender: Male <SPAN style="mso-tab-count: 1">&nbsp;&nbsp;&nbsp; </SPAN></SPAN><SPAN style="FONT-SIZE: 18pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-Roman; mso-bidi-font-size: 19.0pt; mso-no-proof: yes">&#9633;</SPAN><SPAN style="FONT-SIZE: 8pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-Roman; mso-bidi-font-size: 9.0pt"><SPAN style="mso-tab-count: 2">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </SPAN>Female </SPAN><SPAN style="FONT-SIZE: 18pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-Roman; mso-bidi-font-size: 19.0pt; mso-no-proof: yes">&#9633;</SPAN><SPAN style="FONT-SIZE: 8pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-Roman; mso-bidi-font-size: 9.0pt"><o:p></o:p></SPAN></P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><SPAN style="FONT-SIZE: 8pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-Roman; mso-bidi-font-size: 9.0pt">Address:<o:p></o:p></SPAN></P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><SPAN style="FONT-SIZE: 8pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-Roman; mso-bidi-font-size: 9.0pt"><o:p>&nbsp;</o:p></SPAN></P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><SPAN style="FONT-SIZE: 8pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-Roman; mso-bidi-font-size: 9.0pt">Postcode:<o:p></o:p></SPAN></P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><SPAN style="FONT-SIZE: 8pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-Roman; mso-bidi-font-size: 9.0pt"><o:p>&nbsp;</o:p></SPAN></P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><SPAN style="FONT-SIZE: 8pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-Roman; mso-bidi-font-size: 9.0pt">Date of Birth: <SPAN style="mso-tab-count: 4">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </SPAN>Email:<o:p></o:p></SPAN></P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><SPAN style="FONT-SIZE: 8pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-Roman; mso-bidi-font-size: 9.0pt"><o:p>&nbsp;</o:p></SPAN></P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><SPAN style="FONT-SIZE: 8pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-Roman; mso-bidi-font-size: 9.0pt">Telephone Home: <SPAN style="mso-tab-count: 4">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </SPAN></SPAN><st1:City><st1:place><SPAN style="FONT-SIZE: 8pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-Roman; mso-bidi-font-size: 9.0pt">Mobile</SPAN></st1:place></st1:City><SPAN style="FONT-SIZE: 8pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-Roman; mso-bidi-font-size: 9.0pt">:<o:p></o:p></SPAN></P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><B><SPAN style="FONT-SIZE: 8pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-BoldCn; mso-bidi-font-size: 9.0pt"><o:p>&nbsp;</o:p></SPAN></B></P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><B><SPAN style="FONT-SIZE: 8pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-BoldCn; mso-bidi-font-size: 9.0pt">Disability Information<o:p></o:p></SPAN></B></P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><SPAN style="FONT-SIZE: 8pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-Roman; mso-bidi-font-size: 9.0pt">The Disability Discrimination Act 1995 defines a disabled person as anyone with, &#8216;a physical or mental impairment, which has a substantial and long-term adverse effect on his or her ability to carry out normal day-to-day activities.&#8217;<o:p></o:p></SPAN></P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><SPAN style="FONT-SIZE: 8pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-Roman; mso-bidi-font-size: 9.0pt">Do you consider yourself to have a disability? <SPAN style="mso-tab-count: 1">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </SPAN>Yes </SPAN><SPAN style="FONT-SIZE: 18pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-Roman; mso-bidi-font-size: 19.0pt; mso-no-proof: yes">&#9633;</SPAN><SPAN style="FONT-SIZE: 8pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-Roman; mso-bidi-font-size: 9.0pt"> <SPAN style="mso-tab-count: 3">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </SPAN>No </SPAN><SPAN style="FONT-SIZE: 18pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-Roman; mso-bidi-font-size: 19.0pt; mso-no-proof: yes">&#9633;</SPAN><SPAN style="FONT-SIZE: 8pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-Roman; mso-bidi-font-size: 9.0pt"><o:p></o:p></SPAN></P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><SPAN style="FONT-SIZE: 8pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-Roman; mso-bidi-font-size: 9.0pt">If yes, what is the nature of your disability?<o:p></o:p></SPAN></P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><SPAN style="FONT-SIZE: 8pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-Roman; mso-bidi-font-size: 9.0pt">Visual Impairment </SPAN><SPAN style="FONT-SIZE: 18pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-Roman; mso-bidi-font-size: 19.0pt; mso-no-proof: yes">&#9633;</SPAN><SPAN style="FONT-SIZE: 8pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-Roman; mso-bidi-font-size: 9.0pt"> <SPAN style="mso-tab-count: 2">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </SPAN>Hearing Impairment </SPAN><SPAN style="FONT-SIZE: 18pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-Roman; mso-bidi-font-size: 19.0pt; mso-no-proof: yes">&#9633;</SPAN><SPAN style="FONT-SIZE: 8pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-Roman; mso-bidi-font-size: 9.0pt"> <SPAN style="mso-tab-count: 2">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </SPAN>Physical Disability </SPAN><SPAN style="FONT-SIZE: 18pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-Roman; mso-bidi-font-size: 19.0pt; mso-no-proof: yes">&#9633;</SPAN><SPAN style="FONT-SIZE: 8pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-Roman; mso-bidi-font-size: 9.0pt"><o:p></o:p></SPAN></P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><SPAN style="FONT-SIZE: 8pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-Roman; mso-bidi-font-size: 9.0pt">Learning Disability </SPAN><SPAN style="FONT-SIZE: 18pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-Roman; mso-bidi-font-size: 19.0pt; mso-no-proof: yes">&#9633;</SPAN><SPAN style="FONT-SIZE: 8pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-Roman; mso-bidi-font-size: 9.0pt"> <SPAN style="mso-tab-count: 2">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </SPAN>Multiple Disability </SPAN><SPAN style="FONT-SIZE: 18pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-Roman; mso-bidi-font-size: 19.0pt; mso-no-proof: yes">&#9633;<o:p></o:p></SPAN></P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><SPAN style="FONT-SIZE: 8pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-Roman; mso-bidi-font-size: 9.0pt"><o:p>&nbsp;</o:p></SPAN></P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><SPAN style="FONT-SIZE: 8pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-Roman; mso-bidi-font-size: 9.0pt">Other (please specify):<o:p></o:p></SPAN></P><o:p>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><B><SPAN style="FONT-SIZE: 8pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-BoldCn; mso-bidi-font-size: 9.0pt">Cycling Information<o:p></o:p></SPAN></B></P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><SPAN style="FONT-SIZE: 8pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-Roman; mso-bidi-font-size: 9.0pt">Have you taken part in much cycling before? Yes </SPAN><SPAN style="FONT-SIZE: 18pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-Roman; mso-bidi-font-size: 19.0pt; mso-no-proof: yes">&#9633;</SPAN><SPAN style="FONT-SIZE: 8pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-Roman; mso-bidi-font-size: 9.0pt"> No </SPAN><SPAN style="FONT-SIZE: 18pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-Roman; mso-bidi-font-size: 19.0pt; mso-no-proof: yes">&#9633;</SPAN><SPAN style="FONT-SIZE: 8pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-Roman; mso-bidi-font-size: 9.0pt"><o:p></o:p></SPAN></P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><SPAN style="FONT-SIZE: 8pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-Roman; mso-bidi-font-size: 9.0pt">If yes, where have you taken part? (please indicate below)<o:p></o:p></SPAN></P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><SPAN style="FONT-SIZE: 8pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-Roman; mso-bidi-font-size: 9.0pt">Primary School </SPAN><SPAN style="FONT-SIZE: 18pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-Roman; mso-bidi-font-size: 19.0pt; mso-no-proof: yes">&#9633;</SPAN><SPAN style="FONT-SIZE: 8pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-Roman; mso-bidi-font-size: 9.0pt"> <SPAN style="mso-tab-count: 4">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </SPAN>Secondary School </SPAN><SPAN style="FONT-SIZE: 18pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-Roman; mso-bidi-font-size: 19.0pt; mso-no-proof: yes">&#9633;</SPAN><SPAN style="FONT-SIZE: 8pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-Roman; mso-bidi-font-size: 9.0pt"><o:p></o:p></SPAN></P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><SPAN style="FONT-SIZE: 8pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-Roman; mso-bidi-font-size: 9.0pt">Local Authority Coaching Session(s) </SPAN><SPAN style="FONT-SIZE: 18pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-Roman; mso-bidi-font-size: 19.0pt; mso-no-proof: yes">&#9633;</SPAN><SPAN style="FONT-SIZE: 8pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-Roman; mso-bidi-font-size: 9.0pt"> <SPAN style="mso-tab-count: 1">&nbsp;&nbsp; </SPAN>Club </SPAN><SPAN style="FONT-SIZE: 18pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-Roman; mso-bidi-font-size: 19.0pt; mso-no-proof: yes">&#9633;<o:p></o:p></SPAN></P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><SPAN style="FONT-SIZE: 8pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-Roman; mso-bidi-font-size: 9.0pt"><o:p>&nbsp;</o:p></SPAN></P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><SPAN style="FONT-SIZE: 8pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-Roman; mso-bidi-font-size: 9.0pt">Other (please specify):<o:p></o:p></SPAN></P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><SPAN style="FONT-SIZE: 8pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-Roman; mso-bidi-font-size: 9.0pt"><o:p>&nbsp;</o:p></SPAN></P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><B><SPAN style="FONT-SIZE: 8pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-BoldCn; mso-bidi-font-size: 9.0pt">Medical Information<o:p></o:p></SPAN></B></P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><B><SPAN style="FONT-SIZE: 8pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-BoldCn; mso-bidi-font-size: 9.0pt"><o:p>&nbsp;</o:p></SPAN></B></P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><SPAN style="FONT-SIZE: 8pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-Roman; mso-bidi-font-size: 9.0pt">Please detail below any important medical information that our coaches/club should be aware<o:p></o:p></SPAN></P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><SPAN style="FONT-SIZE: 8pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-Roman; mso-bidi-font-size: 9.0pt">of (e.g. epilepsy, asthma, diabetes, a recent injury, etc).</SPAN></P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><SPAN style="FONT-SIZE: 8pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-Roman; mso-bidi-font-size: 9.0pt"><o:p></o:p></SPAN>&nbsp;</P>&#10;<P><SPAN style="FONT-SIZE: 8pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-Roman; mso-bidi-font-family: 'Times New Roman'; mso-bidi-font-size: 9.0pt; mso-fareast-language: EN-US; mso-ansi-language: EN-GB; mso-bidi-language: AR-SA">Medical condition (s) and recommended treatment/actions to be taken if symptoms appear</SPAN></P>&#10;<P><SPAN style="FONT-SIZE: 8pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-Roman; mso-bidi-font-family: 'Times New Roman'; mso-bidi-font-size: 9.0pt; mso-fareast-language: EN-US; mso-ansi-language: EN-GB; mso-bidi-language: AR-SA"></SPAN>&nbsp;</P><SPAN style="FONT-SIZE: 8pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-Roman; mso-bidi-font-family: 'Times New Roman'; mso-bidi-font-size: 9.0pt; mso-fareast-language: EN-US; mso-ansi-language: EN-GB; mso-bidi-language: AR-SA">&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><B><SPAN style="FONT-SIZE: 8pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-BoldCn; mso-bidi-font-size: 9.0pt">Emergency Contact Details (to be completed by parent/carer)<o:p></o:p></SPAN></B></P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><SPAN style="FONT-SIZE: 8pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-Roman; mso-bidi-font-size: 9.0pt">Please indicate below the person who should be contacted in case of an incident/accident<o:p></o:p></SPAN></P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><SPAN style="FONT-SIZE: 8pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-Roman; mso-bidi-font-size: 9.0pt"><o:p>&nbsp;</o:p></SPAN></P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><SPAN style="FONT-SIZE: 8pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-Roman; mso-bidi-font-size: 9.0pt">Contact Name: <SPAN style="mso-tab-count: 6">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </SPAN>Relationship to Child:<o:p></o:p></SPAN></P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><B><SPAN style="FONT-SIZE: 8pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-BoldCn; mso-bidi-font-size: 9.0pt"><o:p>&nbsp;</o:p></SPAN></B></P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><B><SPAN style="FONT-SIZE: 8pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-BoldCn; mso-bidi-font-size: 9.0pt">Emergency Contact Numbers<o:p></o:p></SPAN></B></P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><SPAN style="FONT-SIZE: 8pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-Roman; mso-bidi-font-size: 9.0pt"><o:p>&nbsp;</o:p></SPAN></P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><SPAN style="FONT-SIZE: 8pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-Roman; mso-bidi-font-size: 9.0pt">Home: <SPAN style="mso-tab-count: 7">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </SPAN></SPAN><st1:City><st1:place><SPAN style="FONT-SIZE: 8pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-Roman; mso-bidi-font-size: 9.0pt">Mobile</SPAN></st1:place></st1:City><SPAN style="FONT-SIZE: 8pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-Roman; mso-bidi-font-size: 9.0pt">:<o:p></o:p></SPAN></P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><B><SPAN style="FONT-SIZE: 10pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-BoldCn; mso-bidi-font-size: 11.0pt"><o:p>&nbsp;</o:p></SPAN></B></P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><B><SPAN style="FONT-SIZE: 8pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-BoldCn; mso-bidi-font-size: 9.0pt">Notes</SPAN></B><B><SPAN style="FONT-SIZE: 10pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-BoldCn; mso-bidi-font-size: 11.0pt"><o:p></o:p></SPAN></B></P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><SPAN style="FONT-SIZE: 8pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-Roman; mso-bidi-font-size: 9.0pt">1. <SPAN style="mso-tab-count: 1">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </SPAN>It is part of the British Cycling Code of Conduct to ensure that reasonable steps are&nbsp;taken to establish a safe environment where young people can enjoy&nbsp;developing their cycling skills.<o:p></o:p></SPAN></P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><SPAN style="FONT-SIZE: 8pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-Roman; mso-bidi-font-size: 9.0pt">2. <SPAN style="mso-tab-count: 1">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </SPAN>Parents/carers are welcome to stay and watch the session but this is not compulsory.<o:p></o:p></SPAN></P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><SPAN style="FONT-SIZE: 8pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-Roman; mso-bidi-font-size: 9.0pt">3. <SPAN style="mso-tab-count: 1">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </SPAN>Young people are expected to remain in the session from beginning to end unless they </SPAN><SPAN style="FONT-SIZE: 8pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-Roman; mso-bidi-font-size: 9.0pt">have to leave early. If the young person has to leave early or is&nbsp;&nbsp; being collected by<SPAN style="mso-tab-count: 1"> </SPAN>someone other than the parent/carer, the parent/carer must advise the coach of the details of the arrangement, including who will be collecting the rider.<o:p></o:p></SPAN></P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><SPAN style="FONT-SIZE: 8pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-Roman; mso-bidi-font-size: 9.0pt">4. <SPAN style="mso-tab-count: 1">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </SPAN>It is the young person&#8217;s responsibility to participate in cycling activities in a sporting&nbsp;manner.<o:p></o:p></SPAN></P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><SPAN style="FONT-SIZE: 8pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-Roman; mso-bidi-font-size: 9.0pt">5. <SPAN style="mso-tab-count: 1">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </SPAN>Any young riders who persistently misbehave or put others in danger will be asked to&nbsp;leave the session.<o:p></o:p></SPAN></P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><SPAN style="FONT-SIZE: 8pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-Roman; mso-bidi-font-size: 9.0pt">6. <SPAN style="mso-tab-count: 1">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </SPAN>It is the parent&#8217;s/carer&#8217;s responsibility to ensure that their child&#8217;s bike is in a safe&nbsp;condition to ride.<o:p></o:p></SPAN></P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><SPAN style="FONT-SIZE: 8pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-Roman; mso-bidi-font-size: 9.0pt">7. <SPAN style="mso-tab-count: 1">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </SPAN>A correctly fitting cycling helmet must be worn at all times during the cycling activity sessions.<o:p></o:p></SPAN></P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><SPAN style="FONT-SIZE: 8pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-Roman; mso-bidi-font-size: 9.0pt">8. <SPAN style="mso-tab-count: 1">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </SPAN>For all children under 12 years, coaching sessions will take place at a traffic-free facility.<o:p></o:p></SPAN></P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><SPAN style="FONT-SIZE: 8pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-Roman; mso-bidi-font-size: 9.0pt"><SPAN style="mso-tab-count: 1">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </SPAN>Over 12s may be involved in coaching sessions that take place on the public highway. <SPAN style="mso-tab-count: 1">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </SPAN>Young people are only invited to take part when the coaches feel they are sufficiently responsible for their own actions and have developed the necessary bike handling skills<SPAN style="mso-tab-count: 1"> </SPAN>and fitness levels in order to cope with riding on the public highways.<o:p></o:p></SPAN></P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><SPAN style="FONT-SIZE: 8pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-Roman; mso-bidi-font-size: 9.0pt"><o:p>&nbsp;</o:p></SPAN></P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><B><SPAN style="FONT-SIZE: 8pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-Roman; mso-bidi-font-size: 9.0pt">Please tick if you do not want your child to be involved in cycling activity sessions that take place on the public highways (See note 8 above). </SPAN></B><B><SPAN style="FONT-SIZE: 18pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-Roman; mso-bidi-font-size: 19.0pt; mso-no-proof: yes">&#9633;</SPAN></B><B><SPAN style="FONT-SIZE: 8pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-Roman; mso-bidi-font-size: 9.0pt"><o:p></o:p></SPAN></B></P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><SPAN style="FONT-SIZE: 8pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-Roman; mso-bidi-font-size: 9.0pt"><o:p>&nbsp;</o:p></SPAN></P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><B><SPAN style="FONT-SIZE: 8pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-BoldCn; mso-bidi-font-size: 9.0pt">Parental Consent</SPAN></B><B><SPAN style="FONT-SIZE: 10pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-BoldCn; mso-bidi-font-size: 11.0pt"><o:p></o:p></SPAN></B></P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><SPAN style="FONT-SIZE: 8pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-Roman; mso-bidi-font-size: 9.0pt">I, being the parent/carer of __________________ have read the information contained on<o:p></o:p></SPAN></P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><SPAN style="FONT-SIZE: 8pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-Roman; mso-bidi-font-size: 9.0pt">this form and hereby consent to him/her taking part in the cycling activity sessions and<o:p></o:p></SPAN></P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><SPAN style="FONT-SIZE: 8pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-Roman; mso-bidi-font-size: 9.0pt">understand and agree that he/she participates in cycling activity sessions under the instruction of British Cycling qualified coaches entirely at his/her own risk. I have considered the nature of such sessions and have discussed them with him/her. I am satisfied that he/she is sufficiently responsible and competent to assume full and entire responsibility for his/her own safety under the supervision of a British Cycling qualified coach. I confirm that he/she does not have any disability or medical condition (not disclosed overleaf) that could affect his/her ability to participate safely in cycling activity sessions.<o:p></o:p></SPAN></P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><SPAN style="FONT-SIZE: 8pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-Roman; mso-bidi-font-size: 9.0pt"><o:p>&nbsp;</o:p></SPAN></P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><SPAN style="FONT-SIZE: 8pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-Roman; mso-bidi-font-size: 9.0pt">&#8226; <SPAN style="mso-tab-count: 1">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </SPAN>By returning this completed form, I agree to the child named above taking part in the<o:p></o:p></SPAN></P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><SPAN style="FONT-SIZE: 8pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-Roman; mso-bidi-font-size: 9.0pt"><SPAN style="mso-tab-count: 1">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </SPAN>activities of the club<o:p></o:p></SPAN></P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><SPAN style="FONT-SIZE: 8pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-Roman; mso-bidi-font-size: 9.0pt">&#8226; <SPAN style="mso-tab-count: 1">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </SPAN>I understand that I will be kept informed of these activities - for example timing and<o:p></o:p></SPAN></P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><SPAN style="FONT-SIZE: 8pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-Roman; mso-bidi-font-size: 9.0pt"><SPAN style="mso-tab-count: 1">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </SPAN>transport details<o:p></o:p></SPAN></P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><SPAN style="FONT-SIZE: 8pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-Roman; mso-bidi-font-size: 9.0pt">&#8226; <SPAN style="mso-tab-count: 1">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </SPAN>I understand that in the event of any injury or illness all reasonable steps will be taken to contact me, and to deal with that injury/illness appropriately<o:p></o:p></SPAN></P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><SPAN style="FONT-SIZE: 8pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-Roman; mso-bidi-font-size: 9.0pt"><o:p>&nbsp;</o:p></SPAN></P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><SPAN style="FONT-SIZE: 8pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-Roman; mso-bidi-font-size: 9.0pt">Name of Parent/Carer:<o:p></o:p></SPAN></P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><SPAN style="FONT-SIZE: 8pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-Roman; mso-bidi-font-size: 9.0pt"><o:p>&nbsp;</o:p></SPAN></P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><SPAN style="FONT-SIZE: 8pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-Roman; mso-bidi-font-size: 9.0pt">Signature of Parent/Carer: <SPAN style="mso-tab-count: 5">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </SPAN>Date:<o:p></o:p></SPAN></P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><SPAN style="FONT-SIZE: 8pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-Roman; mso-bidi-font-size: 9.0pt"><o:p>&nbsp;</o:p></SPAN></P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><SPAN style="FONT-SIZE: 8pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-Roman; mso-bidi-font-size: 9.0pt">Once completed please return this form to: </SPAN></P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><SPAN style="FONT-SIZE: 8pt; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-Roman; mso-bidi-font-size: 9.0pt"><o:p></o:p></SPAN>&nbsp;</P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><FONT size=3><FONT face=Arial><SPAN style="mso-bidi-font-family: Arial">Alistair Cameron, Treasurer, </SPAN><st1:Street><st1:address><SPAN style="mso-bidi-font-family: Arial">29 Knox Street</SPAN></st1:address></st1:Street><SPAN style="mso-bidi-font-family: Arial">, Rodley, Leeds LS13&nbsp;1LZ<SPAN style="mso-spacerun: yes">&nbsp;&nbsp; </SPAN>with the appropriate payment, cheques made payable to Leeds Mercury CC,&nbsp;thanks</SPAN></FONT></FONT></P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><FONT size=3><FONT face=Arial><SPAN style="mso-bidi-font-family: Arial"></SPAN></FONT></FONT><SPAN style="FONT-SIZE: 10pt; mso-bidi-font-family: Arial; mso-bidi-font-size: 12.0pt"><o:p></o:p></SPAN>&nbsp;</P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt">&nbsp;</P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt">&nbsp;</P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt">&nbsp;</P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt">&nbsp;</P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt">&nbsp;</P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt">&nbsp;</P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt">&nbsp;</P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt">&nbsp;</P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt">&nbsp;</P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt">&nbsp;</P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt">&nbsp;</P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt">&nbsp;</P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt">&nbsp;</P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt">&nbsp;</P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt">&nbsp;</P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt">&nbsp;</P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt">&nbsp;</P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt">&nbsp;</P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt">&nbsp;</P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt">&nbsp;</P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt">&nbsp;</P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt">&nbsp;</P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt">&nbsp;</P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt">&nbsp;</P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt">&nbsp;</P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt">&nbsp;</P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt">&nbsp;</P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt">&nbsp;</P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt">&nbsp;</P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt">&nbsp;</P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt">&nbsp;</P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt">&nbsp;</P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt">&nbsp;</P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt">&nbsp;</P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt">&nbsp;</P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt">&nbsp;</P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt">&nbsp;</P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt">&nbsp;</P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><SPAN style="FONT-SIZE: 10pt; mso-bidi-font-family: Arial; mso-bidi-font-size: 12.0pt"><o:p></o:p></SPAN>&nbsp;</P><SPAN style="FONT-SIZE: 10pt; mso-bidi-font-family: Arial; mso-bidi-font-size: 12.0pt"><o:p>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><B><SPAN style="FONT-SIZE: 19pt; COLOR: #0b0d58; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-BoldCn; mso-bidi-font-size: 20.0pt"><FONT color=#000000>Sports Equity Monitoring<o:p></o:p></FONT></SPAN></B></P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><SPAN style="FONT-SIZE: 10pt; COLOR: #0b0d58; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-Roman; mso-bidi-font-size: 12.0pt"><o:p><FONT color=#000000>&nbsp;</FONT></o:p></SPAN></P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><SPAN style="FONT-SIZE: 10pt; COLOR: #0b0d58; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-Roman; mso-bidi-font-size: 12.0pt"><FONT color=#000000>Whilst it is not compulsory that this section is completed, the following paragraph explains why it is important.<o:p></o:p></FONT></SPAN></P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><SPAN style="FONT-SIZE: 10pt; COLOR: #0b0d58; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-Roman; mso-bidi-font-size: 12.0pt"><o:p><FONT color=#000000>&nbsp;</FONT></o:p></SPAN></P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><SPAN style="FONT-SIZE: 10pt; COLOR: #0b0d58; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-Roman; mso-bidi-font-size: 12.0pt"><FONT color=#000000>Sport can and does play a major role in promoting the inclusion of all groups in society; however, inequalities have historically existed within sport, particularly in relation to gender, race and disability. British Cycling is committed to promoting and developing sports equity, which is about fairness in sport, equality of access, recognising inequalities and taking steps to address them. By monitoring the profile of young people in our clubs we can identify any issues relating to under&#8209;representation of different groups and can develop strategies to ensure that all young people have the opportunity to develop and progress in cycling.<o:p></o:p></FONT></SPAN></P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><SPAN style="FONT-SIZE: 10pt; COLOR: #0b0d58; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-Roman; mso-bidi-font-size: 12.0pt"><o:p><FONT color=#000000>&nbsp;</FONT></o:p></SPAN></P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><B><SPAN style="FONT-SIZE: 10pt; COLOR: #0b0d58; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-Roman; mso-bidi-font-size: 12.0pt"><FONT color=#000000>Ethnicity - In order to help us monitor our membership, can you please tick one of the following boxes to identify your ethnic group:<o:p></o:p></FONT></SPAN></B></P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><B><SPAN style="FONT-SIZE: 10pt; COLOR: #0b0d58; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-Roman; mso-bidi-font-size: 12.0pt"><o:p>&nbsp;</o:p></SPAN></B><B><SPAN style="FONT-SIZE: 10pt; COLOR: #0b0d58; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-Roman; mso-bidi-font-size: 12.0pt"><o:p><FONT color=#000000>&nbsp;</FONT></o:p></SPAN></B></P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt">&#10;<TABLE class=MsoNormalTable style="MARGIN: auto auto auto 0.5pt; BORDER-COLLAPSE: collapse; mso-table-layout-alt: fixed; mso-padding-alt: 0cm 0cm 0cm 0cm" cellSpacing=0 cellPadding=0 border=0>&#10;<TBODY>&#10;<TR style="HEIGHT: 19.25pt; mso-yfti-irow: 0">&#10;<TD style="BORDER-RIGHT: #d4d0c8; PADDING-RIGHT: 0cm; BORDER-TOP: #0b0d58 1pt solid; PADDING-LEFT: 0cm; BACKGROUND: #0b0d58; PADDING-BOTTOM: 0cm; BORDER-LEFT: #0b0d58 1pt solid; WIDTH: 168.45pt; PADDING-TOP: 0cm; BORDER-BOTTOM: #d4d0c8; HEIGHT: 19.25pt" vAlign=top width=225>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><FONT color=#000000><B><SPAN style="COLOR: white; FONT-FAMILY: Verdana">White</SPAN></B><SPAN style="FONT-SIZE: 12pt"><o:p></o:p></SPAN></FONT></P></TD>&#10;<TD style="BORDER-RIGHT: #0b0d58 1pt solid; PADDING-RIGHT: 0cm; BORDER-TOP: #0b0d58 1pt solid; PADDING-LEFT: 0cm; BACKGROUND: #0b0d58; PADDING-BOTTOM: 0cm; BORDER-LEFT: #d4d0c8; WIDTH: 22.3pt; PADDING-TOP: 0cm; BORDER-BOTTOM: #d4d0c8; HEIGHT: 19.25pt" vAlign=top width=30>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: center" align=center><SPAN style="FONT-SIZE: 12pt"><o:p><FONT face=Arial color=#000000>&nbsp;</FONT></o:p></SPAN></P></TD></TR>&#10;<TR style="HEIGHT: 24.6pt; mso-yfti-irow: 1">&#10;<TD style="BORDER-RIGHT: #d4d0c8; PADDING-RIGHT: 0cm; BORDER-TOP: #d4d0c8; PADDING-LEFT: 0cm; PADDING-BOTTOM: 0cm; BORDER-LEFT: #0b0d58 1pt solid; WIDTH: 168.45pt; PADDING-TOP: 0cm; BORDER-BOTTOM: #d4d0c8; HEIGHT: 24.6pt; BACKGROUND-COLOR: transparent" vAlign=top width=225>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><FONT color=#000000><B><SPAN style="FONT-SIZE: 8pt; COLOR: #0b0d58; FONT-FAMILY: Verdana">British</SPAN></B><SPAN style="FONT-SIZE: 12pt"><o:p></o:p></SPAN></FONT></P></TD>&#10;<TD style="BORDER-RIGHT: #0b0d58 1pt solid; PADDING-RIGHT: 0cm; BORDER-TOP: #d4d0c8; PADDING-LEFT: 0cm; PADDING-BOTTOM: 0cm; BORDER-LEFT: #d4d0c8; WIDTH: 22.3pt; PADDING-TOP: 0cm; BORDER-BOTTOM: #d4d0c8; HEIGHT: 24.6pt; BACKGROUND-COLOR: transparent" vAlign=top width=30>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: center" align=center><FONT face=Arial><FONT color=#000000><B><SPAN style="FONT-SIZE: 16pt; COLOR: #0b0d58; mso-no-proof: yes">&#9633;</SPAN></B><SPAN style="FONT-SIZE: 12pt"><o:p></o:p></SPAN></FONT></FONT></P></TD></TR>&#10;<TR style="HEIGHT: 24.6pt; mso-yfti-irow: 2">&#10;<TD style="BORDER-RIGHT: #d4d0c8; PADDING-RIGHT: 0cm; BORDER-TOP: #d4d0c8; PADDING-LEFT: 0cm; PADDING-BOTTOM: 0cm; BORDER-LEFT: #0b0d58 1pt solid; WIDTH: 168.45pt; PADDING-TOP: 0cm; BORDER-BOTTOM: #d4d0c8; HEIGHT: 24.6pt; BACKGROUND-COLOR: transparent" vAlign=top width=225>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><FONT color=#000000><B><SPAN style="FONT-SIZE: 8pt; COLOR: #0b0d58; FONT-FAMILY: Verdana">Irish</SPAN></B><SPAN style="FONT-SIZE: 12pt"><o:p></o:p></SPAN></FONT></P></TD>&#10;<TD style="BORDER-RIGHT: #0b0d58 1pt solid; PADDING-RIGHT: 0cm; BORDER-TOP: #d4d0c8; PADDING-LEFT: 0cm; PADDING-BOTTOM: 0cm; BORDER-LEFT: #d4d0c8; WIDTH: 22.3pt; PADDING-TOP: 0cm; BORDER-BOTTOM: #d4d0c8; HEIGHT: 24.6pt; BACKGROUND-COLOR: transparent" vAlign=top width=30>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: center" align=center><FONT face=Arial><FONT color=#000000><B><SPAN style="FONT-SIZE: 16pt; COLOR: #0b0d58; mso-no-proof: yes">&#9633;</SPAN></B><SPAN style="FONT-SIZE: 12pt"><o:p></o:p></SPAN></FONT></FONT></P></TD></TR>&#10;<TR style="HEIGHT: 15.7pt; mso-yfti-irow: 3">&#10;<TD style="BORDER-RIGHT: #d4d0c8; PADDING-RIGHT: 0cm; BORDER-TOP: #d4d0c8; PADDING-LEFT: 0cm; PADDING-BOTTOM: 0cm; BORDER-LEFT: #0b0d58 1pt solid; WIDTH: 168.45pt; PADDING-TOP: 0cm; BORDER-BOTTOM: #d4d0c8; HEIGHT: 15.7pt; BACKGROUND-COLOR: transparent" vAlign=top width=225>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><FONT color=#000000><B><SPAN style="FONT-SIZE: 8pt; COLOR: #0b0d58; FONT-FAMILY: Verdana">Any other white background (please specify):</SPAN></B><SPAN style="FONT-SIZE: 12pt"><o:p></o:p></SPAN></FONT></P></TD>&#10;<TD style="BORDER-RIGHT: #0b0d58 1pt solid; PADDING-RIGHT: 0cm; BORDER-TOP: #d4d0c8; PADDING-LEFT: 0cm; PADDING-BOTTOM: 0cm; BORDER-LEFT: #d4d0c8; WIDTH: 22.3pt; PADDING-TOP: 0cm; BORDER-BOTTOM: #d4d0c8; HEIGHT: 15.7pt; BACKGROUND-COLOR: transparent" vAlign=top width=30>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: center" align=center><SPAN style="FONT-SIZE: 12pt"><o:p><FONT face=Arial color=#000000>&nbsp;</FONT></o:p></SPAN></P></TD></TR>&#10;<TR style="HEIGHT: 15.7pt; mso-yfti-irow: 4">&#10;<TD style="BORDER-RIGHT: #d4d0c8; PADDING-RIGHT: 0cm; BORDER-TOP: #d4d0c8; PADDING-LEFT: 0cm; PADDING-BOTTOM: 0cm; BORDER-LEFT: #0b0d58 1pt solid; WIDTH: 168.45pt; PADDING-TOP: 0cm; BORDER-BOTTOM: #d4d0c8; HEIGHT: 15.7pt; BACKGROUND-COLOR: transparent" vAlign=top width=225>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><SPAN style="FONT-SIZE: 12pt"><o:p><FONT face=Arial color=#000000>&nbsp;</FONT></o:p></SPAN></P></TD>&#10;<TD style="BORDER-RIGHT: #0b0d58 1pt solid; PADDING-RIGHT: 0cm; BORDER-TOP: #d4d0c8; PADDING-LEFT: 0cm; PADDING-BOTTOM: 0cm; BORDER-LEFT: #d4d0c8; WIDTH: 22.3pt; PADDING-TOP: 0cm; BORDER-BOTTOM: #d4d0c8; HEIGHT: 15.7pt; BACKGROUND-COLOR: transparent" vAlign=top width=30>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: center" align=center><SPAN style="FONT-SIZE: 12pt"><o:p><FONT face=Arial color=#000000>&nbsp;</FONT></o:p></SPAN></P></TD></TR>&#10;<TR style="HEIGHT: 9.25pt; mso-yfti-irow: 5; mso-yfti-lastrow: yes">&#10;<TD style="BORDER-RIGHT: #d4d0c8; PADDING-RIGHT: 0cm; BORDER-TOP: #d4d0c8; PADDING-LEFT: 0cm; PADDING-BOTTOM: 0cm; BORDER-LEFT: #0b0d58 1pt solid; WIDTH: 168.45pt; PADDING-TOP: 0cm; BORDER-BOTTOM: #0b0d58 1pt solid; HEIGHT: 9.25pt; BACKGROUND-COLOR: transparent" vAlign=top width=225>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><SPAN style="FONT-SIZE: 12pt"><o:p><FONT face=Arial color=#000000>&nbsp;</FONT></o:p></SPAN></P></TD>&#10;<TD style="BORDER-RIGHT: #0b0d58 1pt solid; PADDING-RIGHT: 0cm; BORDER-TOP: #d4d0c8; PADDING-LEFT: 0cm; PADDING-BOTTOM: 0cm; BORDER-LEFT: #d4d0c8; WIDTH: 22.3pt; PADDING-TOP: 0cm; BORDER-BOTTOM: #0b0d58 1pt solid; HEIGHT: 9.25pt; BACKGROUND-COLOR: transparent" vAlign=top width=30>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: center" align=center><SPAN style="FONT-SIZE: 12pt"><o:p><FONT face=Arial color=#000000>&nbsp;</FONT></o:p></SPAN></P></TD></TR></TBODY></TABLE>&#10;<TABLE class=MsoNormalTable style="MARGIN: auto 6.75pt; BORDER-COLLAPSE: collapse; mso-table-layout-alt: fixed; mso-padding-alt: 0cm 0cm 0cm 0cm; mso-table-lspace: 9.0pt; mso-table-rspace: 9.0pt; mso-table-anchor-vertical: paragraph; mso-table-anchor-horizontal: page; mso-table-left: 333.0pt; mso-table-top: -115.5pt" cellSpacing=0 cellPadding=0 align=left border=0>&#10;<TBODY>&#10;<TR style="HEIGHT: 19.6pt; mso-yfti-irow: 0">&#10;<TD style="BORDER-RIGHT: #d4d0c8; PADDING-RIGHT: 0cm; BORDER-TOP: #0b0d58 1pt solid; PADDING-LEFT: 0cm; BACKGROUND: #0b0d58; PADDING-BOTTOM: 0cm; BORDER-LEFT: #0b0d58 1pt solid; WIDTH: 184.6pt; PADDING-TOP: 0cm; BORDER-BOTTOM: #d4d0c8; HEIGHT: 19.6pt" vAlign=top width=246>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; mso-element: frame; mso-element-frame-hspace: 9.0pt; mso-element-wrap: around; mso-element-anchor-vertical: paragraph; mso-element-anchor-horizontal: page; mso-element-left: 333.05pt; mso-element-top: -115.5pt; mso-height-rule: exactly"><FONT color=#000000><B><SPAN style="COLOR: white; FONT-FAMILY: Verdana">Black or Black British</SPAN></B><SPAN style="FONT-SIZE: 12pt"><o:p></o:p></SPAN></FONT></P></TD>&#10;<TD style="BORDER-RIGHT: #0b0d58 1pt solid; PADDING-RIGHT: 0cm; BORDER-TOP: #0b0d58 1pt solid; PADDING-LEFT: 0cm; BACKGROUND: #0b0d58; PADDING-BOTTOM: 0cm; BORDER-LEFT: #d4d0c8; WIDTH: 24.45pt; PADDING-TOP: 0cm; BORDER-BOTTOM: #d4d0c8; HEIGHT: 19.6pt" vAlign=top width=33>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: center; mso-element: frame; mso-element-frame-hspace: 9.0pt; mso-element-wrap: around; mso-element-anchor-vertical: paragraph; mso-element-anchor-horizontal: page; mso-element-left: 333.05pt; mso-element-top: -115.5pt; mso-height-rule: exactly" align=center><SPAN style="FONT-SIZE: 12pt"><o:p><FONT face=Arial color=#000000>&nbsp;</FONT></o:p></SPAN></P></TD></TR>&#10;<TR style="HEIGHT: 25pt; mso-yfti-irow: 1">&#10;<TD style="BORDER-RIGHT: #d4d0c8; PADDING-RIGHT: 0cm; BORDER-TOP: #d4d0c8; PADDING-LEFT: 0cm; PADDING-BOTTOM: 0cm; BORDER-LEFT: #0b0d58 1pt solid; WIDTH: 184.6pt; PADDING-TOP: 0cm; BORDER-BOTTOM: #d4d0c8; HEIGHT: 25pt; BACKGROUND-COLOR: transparent" vAlign=top width=246>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; mso-element: frame; mso-element-frame-hspace: 9.0pt; mso-element-wrap: around; mso-element-anchor-vertical: paragraph; mso-element-anchor-horizontal: page; mso-element-left: 333.05pt; mso-element-top: -115.5pt; mso-height-rule: exactly"><FONT color=#000000><st1:place><B><SPAN style="FONT-SIZE: 8pt; COLOR: #0b0d58; FONT-FAMILY: Verdana">Caribbean</SPAN></B></st1:place><SPAN style="FONT-SIZE: 12pt"><o:p></o:p></SPAN></FONT></P></TD>&#10;<TD style="BORDER-RIGHT: #0b0d58 1pt solid; PADDING-RIGHT: 0cm; BORDER-TOP: #d4d0c8; PADDING-LEFT: 0cm; PADDING-BOTTOM: 0cm; BORDER-LEFT: #d4d0c8; WIDTH: 24.45pt; PADDING-TOP: 0cm; BORDER-BOTTOM: #d4d0c8; HEIGHT: 25pt; BACKGROUND-COLOR: transparent" vAlign=top width=33>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: center; mso-element: frame; mso-element-frame-hspace: 9.0pt; mso-element-wrap: around; mso-element-anchor-vertical: paragraph; mso-element-anchor-horizontal: page; mso-element-left: 333.05pt; mso-element-top: -115.5pt; mso-height-rule: exactly" align=center><FONT face=Arial><FONT color=#000000><B><SPAN style="FONT-SIZE: 16pt; COLOR: #0b0d58; mso-no-proof: yes">&#9633;</SPAN></B><SPAN style="FONT-SIZE: 12pt"><o:p></o:p></SPAN></FONT></FONT></P></TD></TR>&#10;<TR style="HEIGHT: 25pt; mso-yfti-irow: 2">&#10;<TD style="BORDER-RIGHT: #d4d0c8; PADDING-RIGHT: 0cm; BORDER-TOP: #d4d0c8; PADDING-LEFT: 0cm; PADDING-BOTTOM: 0cm; BORDER-LEFT: #0b0d58 1pt solid; WIDTH: 184.6pt; PADDING-TOP: 0cm; BORDER-BOTTOM: #d4d0c8; HEIGHT: 25pt; BACKGROUND-COLOR: transparent" vAlign=top width=246>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; mso-element: frame; mso-element-frame-hspace: 9.0pt; mso-element-wrap: around; mso-element-anchor-vertical: paragraph; mso-element-anchor-horizontal: page; mso-element-left: 333.05pt; mso-element-top: -115.5pt; mso-height-rule: exactly"><FONT color=#000000><B><SPAN style="FONT-SIZE: 8pt; COLOR: #0b0d58; FONT-FAMILY: Verdana">African</SPAN></B><SPAN style="FONT-SIZE: 12pt"><o:p></o:p></SPAN></FONT></P></TD>&#10;<TD style="BORDER-RIGHT: #0b0d58 1pt solid; PADDING-RIGHT: 0cm; BORDER-TOP: #d4d0c8; PADDING-LEFT: 0cm; PADDING-BOTTOM: 0cm; BORDER-LEFT: #d4d0c8; WIDTH: 24.45pt; PADDING-TOP: 0cm; BORDER-BOTTOM: #d4d0c8; HEIGHT: 25pt; BACKGROUND-COLOR: transparent" vAlign=top width=33>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: center; mso-element: frame; mso-element-frame-hspace: 9.0pt; mso-element-wrap: around; mso-element-anchor-vertical: paragraph; mso-element-anchor-horizontal: page; mso-element-left: 333.05pt; mso-element-top: -115.5pt; mso-height-rule: exactly" align=center><FONT face=Arial><FONT color=#000000><B><SPAN style="FONT-SIZE: 16pt; COLOR: #0b0d58; mso-no-proof: yes">&#9633;</SPAN></B><SPAN style="FONT-SIZE: 12pt"><o:p></o:p></SPAN></FONT></FONT></P></TD></TR>&#10;<TR style="HEIGHT: 16pt; mso-yfti-irow: 3">&#10;<TD style="BORDER-RIGHT: #d4d0c8; PADDING-RIGHT: 0cm; BORDER-TOP: #d4d0c8; PADDING-LEFT: 0cm; PADDING-BOTTOM: 0cm; BORDER-LEFT: #0b0d58 1pt solid; WIDTH: 184.6pt; PADDING-TOP: 0cm; BORDER-BOTTOM: #d4d0c8; HEIGHT: 16pt; BACKGROUND-COLOR: transparent" vAlign=top width=246>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; mso-element: frame; mso-element-frame-hspace: 9.0pt; mso-element-wrap: around; mso-element-anchor-vertical: paragraph; mso-element-anchor-horizontal: page; mso-element-left: 333.05pt; mso-element-top: -115.5pt; mso-height-rule: exactly"><FONT color=#000000><B><SPAN style="FONT-SIZE: 8pt; COLOR: #0b0d58; FONT-FAMILY: Verdana">Any other Black background (please specify):</SPAN></B><SPAN style="FONT-SIZE: 12pt"><o:p></o:p></SPAN></FONT></P></TD>&#10;<TD style="BORDER-RIGHT: #0b0d58 1pt solid; PADDING-RIGHT: 0cm; BORDER-TOP: #d4d0c8; PADDING-LEFT: 0cm; PADDING-BOTTOM: 0cm; BORDER-LEFT: #d4d0c8; WIDTH: 24.45pt; PADDING-TOP: 0cm; BORDER-BOTTOM: #d4d0c8; HEIGHT: 16pt; BACKGROUND-COLOR: transparent" vAlign=top width=33>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: center; mso-element: frame; mso-element-frame-hspace: 9.0pt; mso-element-wrap: around; mso-element-anchor-vertical: paragraph; mso-element-anchor-horizontal: page; mso-element-left: 333.05pt; mso-element-top: -115.5pt; mso-height-rule: exactly" align=center><SPAN style="FONT-SIZE: 12pt"><o:p><FONT face=Arial color=#000000>&nbsp;</FONT></o:p></SPAN></P></TD></TR>&#10;<TR style="HEIGHT: 16pt; mso-yfti-irow: 4">&#10;<TD style="BORDER-RIGHT: #d4d0c8; PADDING-RIGHT: 0cm; BORDER-TOP: #d4d0c8; PADDING-LEFT: 0cm; PADDING-BOTTOM: 0cm; BORDER-LEFT: #0b0d58 1pt solid; WIDTH: 184.6pt; PADDING-TOP: 0cm; BORDER-BOTTOM: #d4d0c8; HEIGHT: 16pt; BACKGROUND-COLOR: transparent" vAlign=top width=246>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; mso-element: frame; mso-element-frame-hspace: 9.0pt; mso-element-wrap: around; mso-element-anchor-vertical: paragraph; mso-element-anchor-horizontal: page; mso-element-left: 333.05pt; mso-element-top: -115.5pt; mso-height-rule: exactly"><SPAN style="FONT-SIZE: 12pt"><o:p><FONT face=Arial color=#000000>&nbsp;</FONT></o:p></SPAN></P></TD>&#10;<TD style="BORDER-RIGHT: #0b0d58 1pt solid; PADDING-RIGHT: 0cm; BORDER-TOP: #d4d0c8; PADDING-LEFT: 0cm; PADDING-BOTTOM: 0cm; BORDER-LEFT: #d4d0c8; WIDTH: 24.45pt; PADDING-TOP: 0cm; BORDER-BOTTOM: #d4d0c8; HEIGHT: 16pt; BACKGROUND-COLOR: transparent" vAlign=top width=33>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: center; mso-element: frame; mso-element-frame-hspace: 9.0pt; mso-element-wrap: around; mso-element-anchor-vertical: paragraph; mso-element-anchor-horizontal: page; mso-element-left: 333.05pt; mso-element-top: -115.5pt; mso-height-rule: exactly" align=center><SPAN style="FONT-SIZE: 12pt"><o:p><FONT face=Arial color=#000000>&nbsp;</FONT></o:p></SPAN></P></TD></TR>&#10;<TR style="HEIGHT: 9.4pt; mso-yfti-irow: 5; mso-yfti-lastrow: yes">&#10;<TD style="BORDER-RIGHT: #d4d0c8; PADDING-RIGHT: 0cm; BORDER-TOP: #d4d0c8; PADDING-LEFT: 0cm; PADDING-BOTTOM: 0cm; BORDER-LEFT: #0b0d58 1pt solid; WIDTH: 184.6pt; PADDING-TOP: 0cm; BORDER-BOTTOM: #0b0d58 1pt solid; HEIGHT: 9.4pt; BACKGROUND-COLOR: transparent" vAlign=top width=246>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; mso-element: frame; mso-element-frame-hspace: 9.0pt; mso-element-wrap: around; mso-element-anchor-vertical: paragraph; mso-element-anchor-horizontal: page; mso-element-left: 333.05pt; mso-element-top: -115.5pt; mso-height-rule: exactly"><SPAN style="FONT-SIZE: 12pt"><o:p><FONT face=Arial color=#000000>&nbsp;</FONT></o:p></SPAN></P></TD>&#10;<TD style="BORDER-RIGHT: #0b0d58 1pt solid; PADDING-RIGHT: 0cm; BORDER-TOP: #d4d0c8; PADDING-LEFT: 0cm; PADDING-BOTTOM: 0cm; BORDER-LEFT: #d4d0c8; WIDTH: 24.45pt; PADDING-TOP: 0cm; BORDER-BOTTOM: #0b0d58 1pt solid; HEIGHT: 9.4pt; BACKGROUND-COLOR: transparent" vAlign=top width=33>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: center; mso-element: frame; mso-element-frame-hspace: 9.0pt; mso-element-wrap: around; mso-element-anchor-vertical: paragraph; mso-element-anchor-horizontal: page; mso-element-left: 333.05pt; mso-element-top: -115.5pt; mso-height-rule: exactly" align=center><SPAN style="FONT-SIZE: 12pt"><o:p><FONT face=Arial color=#000000>&nbsp;</FONT></o:p></SPAN></P></TD></TR></TBODY></TABLE></P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><SPAN style="FONT-SIZE: 10pt; COLOR: #0b0d58; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-Roman; mso-bidi-font-size: 12.0pt"><o:p><FONT color=#000000>&nbsp;</FONT></o:p></SPAN></P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt">&#10;<TABLE class=MsoNormalTable style="MARGIN: auto auto auto 0.5pt; BORDER-COLLAPSE: collapse; mso-table-layout-alt: fixed; mso-padding-alt: 0cm 0cm 0cm 0cm" cellSpacing=0 cellPadding=0 border=0>&#10;<TBODY>&#10;<TR style="HEIGHT: 17.95pt; mso-yfti-irow: 0">&#10;<TD style="BORDER-RIGHT: #d4d0c8; PADDING-RIGHT: 0cm; BORDER-TOP: #0b0d58 1pt solid; PADDING-LEFT: 0cm; BACKGROUND: #0b0d58; PADDING-BOTTOM: 0cm; BORDER-LEFT: #0b0d58 1pt solid; WIDTH: 168.45pt; PADDING-TOP: 0cm; BORDER-BOTTOM: #d4d0c8; HEIGHT: 17.95pt" vAlign=top width=225>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><FONT color=#000000><B><SPAN style="COLOR: white; FONT-FAMILY: Verdana">Mixed</SPAN></B><SPAN style="FONT-SIZE: 12pt"><o:p></o:p></SPAN></FONT></P></TD>&#10;<TD style="BORDER-RIGHT: #0b0d58 1pt solid; PADDING-RIGHT: 0cm; BORDER-TOP: #0b0d58 1pt solid; PADDING-LEFT: 0cm; BACKGROUND: #0b0d58; PADDING-BOTTOM: 0cm; BORDER-LEFT: #d4d0c8; WIDTH: 22.3pt; PADDING-TOP: 0cm; BORDER-BOTTOM: #d4d0c8; HEIGHT: 17.95pt" vAlign=top width=30>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: center" align=center><SPAN style="FONT-SIZE: 12pt"><o:p><FONT face=Arial color=#000000>&nbsp;</FONT></o:p></SPAN></P></TD></TR>&#10;<TR style="HEIGHT: 22.9pt; mso-yfti-irow: 1">&#10;<TD style="BORDER-RIGHT: #d4d0c8; PADDING-RIGHT: 0cm; BORDER-TOP: #d4d0c8; PADDING-LEFT: 0cm; PADDING-BOTTOM: 0cm; BORDER-LEFT: #0b0d58 1pt solid; WIDTH: 168.45pt; PADDING-TOP: 0cm; BORDER-BOTTOM: #d4d0c8; HEIGHT: 22.9pt; BACKGROUND-COLOR: transparent" vAlign=top width=225>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><FONT color=#000000><B><SPAN style="FONT-SIZE: 8pt; COLOR: #0b0d58; FONT-FAMILY: Verdana">White and Black Caribbean</SPAN></B><SPAN style="FONT-SIZE: 12pt"><o:p></o:p></SPAN></FONT></P></TD>&#10;<TD style="BORDER-RIGHT: #0b0d58 1pt solid; PADDING-RIGHT: 0cm; BORDER-TOP: #d4d0c8; PADDING-LEFT: 0cm; PADDING-BOTTOM: 0cm; BORDER-LEFT: #d4d0c8; WIDTH: 22.3pt; PADDING-TOP: 0cm; BORDER-BOTTOM: #d4d0c8; HEIGHT: 22.9pt; BACKGROUND-COLOR: transparent" vAlign=top width=30>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: center" align=center><FONT face=Arial><FONT color=#000000><B><SPAN style="FONT-SIZE: 16pt; COLOR: #0b0d58; mso-no-proof: yes">&#9633;</SPAN></B><SPAN style="FONT-SIZE: 12pt"><o:p></o:p></SPAN></FONT></FONT></P></TD></TR>&#10;<TR style="HEIGHT: 22.9pt; mso-yfti-irow: 2">&#10;<TD style="BORDER-RIGHT: #d4d0c8; PADDING-RIGHT: 0cm; BORDER-TOP: #d4d0c8; PADDING-LEFT: 0cm; PADDING-BOTTOM: 0cm; BORDER-LEFT: #0b0d58 1pt solid; WIDTH: 168.45pt; PADDING-TOP: 0cm; BORDER-BOTTOM: #d4d0c8; HEIGHT: 22.9pt; BACKGROUND-COLOR: transparent" vAlign=top width=225>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><FONT color=#000000><B><SPAN style="FONT-SIZE: 8pt; COLOR: #0b0d58; FONT-FAMILY: Verdana">White and Black African</SPAN></B><SPAN style="FONT-SIZE: 12pt"><o:p></o:p></SPAN></FONT></P></TD>&#10;<TD style="BORDER-RIGHT: #0b0d58 1pt solid; PADDING-RIGHT: 0cm; BORDER-TOP: #d4d0c8; PADDING-LEFT: 0cm; PADDING-BOTTOM: 0cm; BORDER-LEFT: #d4d0c8; WIDTH: 22.3pt; PADDING-TOP: 0cm; BORDER-BOTTOM: #d4d0c8; HEIGHT: 22.9pt; BACKGROUND-COLOR: transparent" vAlign=top width=30>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: center" align=center><FONT face=Arial><FONT color=#000000><B><SPAN style="FONT-SIZE: 16pt; COLOR: #0b0d58; mso-no-proof: yes">&#9633;</SPAN></B><SPAN style="FONT-SIZE: 12pt"><o:p></o:p></SPAN></FONT></FONT></P></TD></TR>&#10;<TR style="HEIGHT: 17.5pt; mso-yfti-irow: 3">&#10;<TD style="BORDER-RIGHT: #d4d0c8; PADDING-RIGHT: 0cm; BORDER-TOP: #d4d0c8; PADDING-LEFT: 0cm; PADDING-BOTTOM: 0cm; BORDER-LEFT: #0b0d58 1pt solid; WIDTH: 168.45pt; PADDING-TOP: 0cm; BORDER-BOTTOM: #d4d0c8; HEIGHT: 17.5pt; BACKGROUND-COLOR: transparent" vAlign=top width=225>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><FONT color=#000000><B><SPAN style="FONT-SIZE: 8pt; COLOR: #0b0d58; FONT-FAMILY: Verdana">Any other Mixed background (please specify):</SPAN></B><SPAN style="FONT-SIZE: 12pt"><o:p></o:p></SPAN></FONT></P></TD>&#10;<TD style="BORDER-RIGHT: #0b0d58 1pt solid; PADDING-RIGHT: 0cm; BORDER-TOP: #d4d0c8; PADDING-LEFT: 0cm; PADDING-BOTTOM: 0cm; BORDER-LEFT: #d4d0c8; WIDTH: 22.3pt; PADDING-TOP: 0cm; BORDER-BOTTOM: #d4d0c8; HEIGHT: 17.5pt; BACKGROUND-COLOR: transparent" vAlign=top width=30>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: center" align=center><SPAN style="FONT-SIZE: 12pt"><o:p><FONT face=Arial color=#000000>&nbsp;</FONT></o:p></SPAN></P></TD></TR>&#10;<TR style="HEIGHT: 14.65pt; mso-yfti-irow: 4">&#10;<TD style="BORDER-RIGHT: #d4d0c8; PADDING-RIGHT: 0cm; BORDER-TOP: #d4d0c8; PADDING-LEFT: 0cm; PADDING-BOTTOM: 0cm; BORDER-LEFT: #0b0d58 1pt solid; WIDTH: 168.45pt; PADDING-TOP: 0cm; BORDER-BOTTOM: #d4d0c8; HEIGHT: 14.65pt; BACKGROUND-COLOR: transparent" vAlign=top width=225>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><SPAN style="FONT-SIZE: 12pt"><o:p><FONT face=Arial color=#000000>&nbsp;</FONT></o:p></SPAN></P></TD>&#10;<TD style="BORDER-RIGHT: #0b0d58 1pt solid; PADDING-RIGHT: 0cm; BORDER-TOP: #d4d0c8; PADDING-LEFT: 0cm; PADDING-BOTTOM: 0cm; BORDER-LEFT: #d4d0c8; WIDTH: 22.3pt; PADDING-TOP: 0cm; BORDER-BOTTOM: #d4d0c8; HEIGHT: 14.65pt; BACKGROUND-COLOR: transparent" vAlign=top width=30>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: center" align=center><SPAN style="FONT-SIZE: 12pt"><o:p><FONT face=Arial color=#000000>&nbsp;</FONT></o:p></SPAN></P></TD></TR>&#10;<TR style="HEIGHT: 8.6pt; mso-yfti-irow: 5; mso-yfti-lastrow: yes">&#10;<TD style="BORDER-RIGHT: #d4d0c8; PADDING-RIGHT: 0cm; BORDER-TOP: #d4d0c8; PADDING-LEFT: 0cm; PADDING-BOTTOM: 0cm; BORDER-LEFT: #0b0d58 1pt solid; WIDTH: 168.45pt; PADDING-TOP: 0cm; BORDER-BOTTOM: #0b0d58 1pt solid; HEIGHT: 8.6pt; BACKGROUND-COLOR: transparent" vAlign=top width=225>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><SPAN style="FONT-SIZE: 12pt"><o:p><FONT face=Arial color=#000000>&nbsp;</FONT></o:p></SPAN></P></TD>&#10;<TD style="BORDER-RIGHT: #0b0d58 1pt solid; PADDING-RIGHT: 0cm; BORDER-TOP: #d4d0c8; PADDING-LEFT: 0cm; PADDING-BOTTOM: 0cm; BORDER-LEFT: #d4d0c8; WIDTH: 22.3pt; PADDING-TOP: 0cm; BORDER-BOTTOM: #0b0d58 1pt solid; HEIGHT: 8.6pt; BACKGROUND-COLOR: transparent" vAlign=top width=30>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: center" align=center><SPAN style="FONT-SIZE: 12pt"><o:p><FONT face=Arial color=#000000>&nbsp;</FONT></o:p></SPAN></P></TD></TR></TBODY></TABLE>&#10;<TABLE class=MsoNormalTable style="MARGIN: auto 6.75pt; BORDER-COLLAPSE: collapse; mso-table-layout-alt: fixed; mso-padding-alt: 0cm 0cm 0cm 0cm; mso-table-lspace: 9.0pt; mso-table-rspace: 9.0pt; mso-table-anchor-vertical: paragraph; mso-table-anchor-horizontal: page; mso-table-left: 333.0pt; mso-table-top: -106.3pt" cellSpacing=0 cellPadding=0 align=left border=0>&#10;<TBODY>&#10;<TR style="HEIGHT: 17.05pt; mso-yfti-irow: 0">&#10;<TD style="BORDER-RIGHT: #d4d0c8; PADDING-RIGHT: 0cm; BORDER-TOP: #0b0d58 1pt solid; PADDING-LEFT: 0cm; BACKGROUND: #0b0d58; PADDING-BOTTOM: 0cm; BORDER-LEFT: #0b0d58 1pt solid; WIDTH: 184.6pt; PADDING-TOP: 0cm; BORDER-BOTTOM: #d4d0c8; HEIGHT: 17.05pt" vAlign=top width=246>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; mso-element: frame; mso-element-frame-hspace: 9.0pt; mso-element-wrap: around; mso-element-anchor-vertical: paragraph; mso-element-anchor-horizontal: page; mso-element-left: 333.05pt; mso-element-top: -106.3pt; mso-height-rule: exactly"><FONT color=#000000><B><SPAN style="COLOR: white; FONT-FAMILY: Verdana">Chinese or other ethnic group</SPAN></B><SPAN style="FONT-SIZE: 12pt"><o:p></o:p></SPAN></FONT></P></TD>&#10;<TD style="BORDER-RIGHT: #0b0d58 1pt solid; PADDING-RIGHT: 0cm; BORDER-TOP: #0b0d58 1pt solid; PADDING-LEFT: 0cm; BACKGROUND: #0b0d58; PADDING-BOTTOM: 0cm; BORDER-LEFT: #d4d0c8; WIDTH: 24.45pt; PADDING-TOP: 0cm; BORDER-BOTTOM: #d4d0c8; HEIGHT: 17.05pt" vAlign=top width=33>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: center; mso-element: frame; mso-element-frame-hspace: 9.0pt; mso-element-wrap: around; mso-element-anchor-vertical: paragraph; mso-element-anchor-horizontal: page; mso-element-left: 333.05pt; mso-element-top: -106.3pt; mso-height-rule: exactly" align=center><SPAN style="FONT-SIZE: 12pt"><o:p><FONT face=Arial color=#000000>&nbsp;</FONT></o:p></SPAN></P></TD></TR>&#10;<TR style="HEIGHT: 21.8pt; mso-yfti-irow: 1">&#10;<TD style="BORDER-RIGHT: #d4d0c8; PADDING-RIGHT: 0cm; BORDER-TOP: #d4d0c8; PADDING-LEFT: 0cm; PADDING-BOTTOM: 0cm; BORDER-LEFT: #0b0d58 1pt solid; WIDTH: 184.6pt; PADDING-TOP: 0cm; BORDER-BOTTOM: #d4d0c8; HEIGHT: 21.8pt; BACKGROUND-COLOR: transparent" vAlign=top width=246>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; mso-element: frame; mso-element-frame-hspace: 9.0pt; mso-element-wrap: around; mso-element-anchor-vertical: paragraph; mso-element-anchor-horizontal: page; mso-element-left: 333.05pt; mso-element-top: -106.3pt; mso-height-rule: exactly"><FONT color=#000000><B><SPAN style="FONT-SIZE: 8pt; COLOR: #0b0d58; FONT-FAMILY: Verdana">Chinese</SPAN></B><SPAN style="FONT-SIZE: 12pt"><o:p></o:p></SPAN></FONT></P></TD>&#10;<TD style="BORDER-RIGHT: #0b0d58 1pt solid; PADDING-RIGHT: 0cm; BORDER-TOP: #d4d0c8; PADDING-LEFT: 0cm; PADDING-BOTTOM: 0cm; BORDER-LEFT: #d4d0c8; WIDTH: 24.45pt; PADDING-TOP: 0cm; BORDER-BOTTOM: #d4d0c8; HEIGHT: 21.8pt; BACKGROUND-COLOR: transparent" vAlign=top width=33>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: center; mso-element: frame; mso-element-frame-hspace: 9.0pt; mso-element-wrap: around; mso-element-anchor-vertical: paragraph; mso-element-anchor-horizontal: page; mso-element-left: 333.05pt; mso-element-top: -106.3pt; mso-height-rule: exactly" align=center><FONT face=Arial><FONT color=#000000><B><SPAN style="FONT-SIZE: 16pt; COLOR: #0b0d58; mso-no-proof: yes">&#9633;</SPAN></B><SPAN style="FONT-SIZE: 12pt"><o:p></o:p></SPAN></FONT></FONT></P></TD></TR>&#10;<TR style="HEIGHT: 13.95pt; mso-yfti-irow: 2">&#10;<TD style="BORDER-RIGHT: #d4d0c8; PADDING-RIGHT: 0cm; BORDER-TOP: #d4d0c8; PADDING-LEFT: 0cm; PADDING-BOTTOM: 0cm; BORDER-LEFT: #0b0d58 1pt solid; WIDTH: 184.6pt; PADDING-TOP: 0cm; BORDER-BOTTOM: #d4d0c8; HEIGHT: 13.95pt; BACKGROUND-COLOR: transparent" vAlign=top width=246>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; mso-element: frame; mso-element-frame-hspace: 9.0pt; mso-element-wrap: around; mso-element-anchor-vertical: paragraph; mso-element-anchor-horizontal: page; mso-element-left: 333.05pt; mso-element-top: -106.3pt; mso-height-rule: exactly"><FONT color=#000000><B><SPAN style="FONT-SIZE: 8pt; COLOR: #0b0d58; FONT-FAMILY: Verdana">Any other (please specify):</SPAN></B><SPAN style="FONT-SIZE: 12pt"><o:p></o:p></SPAN></FONT></P></TD>&#10;<TD style="BORDER-RIGHT: #0b0d58 1pt solid; PADDING-RIGHT: 0cm; BORDER-TOP: #d4d0c8; PADDING-LEFT: 0cm; PADDING-BOTTOM: 0cm; BORDER-LEFT: #d4d0c8; WIDTH: 24.45pt; PADDING-TOP: 0cm; BORDER-BOTTOM: #d4d0c8; HEIGHT: 13.95pt; BACKGROUND-COLOR: transparent" vAlign=top width=33>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: center; mso-element: frame; mso-element-frame-hspace: 9.0pt; mso-element-wrap: around; mso-element-anchor-vertical: paragraph; mso-element-anchor-horizontal: page; mso-element-left: 333.05pt; mso-element-top: -106.3pt; mso-height-rule: exactly" align=center><SPAN style="FONT-SIZE: 12pt"><o:p><FONT face=Arial color=#000000>&nbsp;</FONT></o:p></SPAN></P></TD></TR>&#10;<TR style="HEIGHT: 13.95pt; mso-yfti-irow: 3">&#10;<TD style="BORDER-RIGHT: #d4d0c8; PADDING-RIGHT: 0cm; BORDER-TOP: #d4d0c8; PADDING-LEFT: 0cm; PADDING-BOTTOM: 0cm; BORDER-LEFT: #0b0d58 1pt solid; WIDTH: 184.6pt; PADDING-TOP: 0cm; BORDER-BOTTOM: #d4d0c8; HEIGHT: 13.95pt; BACKGROUND-COLOR: transparent" vAlign=top width=246>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; mso-element: frame; mso-element-frame-hspace: 9.0pt; mso-element-wrap: around; mso-element-anchor-vertical: paragraph; mso-element-anchor-horizontal: page; mso-element-left: 333.05pt; mso-element-top: -106.3pt; mso-height-rule: exactly"><SPAN style="FONT-SIZE: 12pt"><o:p><FONT face=Arial color=#000000>&nbsp;</FONT></o:p></SPAN></P></TD>&#10;<TD style="BORDER-RIGHT: #0b0d58 1pt solid; PADDING-RIGHT: 0cm; BORDER-TOP: #d4d0c8; PADDING-LEFT: 0cm; PADDING-BOTTOM: 0cm; BORDER-LEFT: #d4d0c8; WIDTH: 24.45pt; PADDING-TOP: 0cm; BORDER-BOTTOM: #d4d0c8; HEIGHT: 13.95pt; BACKGROUND-COLOR: transparent" vAlign=top width=33>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: center; mso-element: frame; mso-element-frame-hspace: 9.0pt; mso-element-wrap: around; mso-element-anchor-vertical: paragraph; mso-element-anchor-horizontal: page; mso-element-left: 333.05pt; mso-element-top: -106.3pt; mso-height-rule: exactly" align=center><SPAN style="FONT-SIZE: 12pt"><o:p><FONT face=Arial color=#000000>&nbsp;</FONT></o:p></SPAN></P></TD></TR>&#10;<TR style="HEIGHT: 8.2pt; mso-yfti-irow: 4; mso-yfti-lastrow: yes">&#10;<TD style="BORDER-RIGHT: #d4d0c8; PADDING-RIGHT: 0cm; BORDER-TOP: #d4d0c8; PADDING-LEFT: 0cm; PADDING-BOTTOM: 0cm; BORDER-LEFT: #0b0d58 1pt solid; WIDTH: 184.6pt; PADDING-TOP: 0cm; BORDER-BOTTOM: #0b0d58 1pt solid; HEIGHT: 8.2pt; BACKGROUND-COLOR: transparent" vAlign=top width=246>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; mso-element: frame; mso-element-frame-hspace: 9.0pt; mso-element-wrap: around; mso-element-anchor-vertical: paragraph; mso-element-anchor-horizontal: page; mso-element-left: 333.05pt; mso-element-top: -106.3pt; mso-height-rule: exactly"><SPAN style="FONT-SIZE: 12pt"><o:p><FONT face=Arial color=#000000>&nbsp;</FONT></o:p></SPAN></P></TD>&#10;<TD style="BORDER-RIGHT: #0b0d58 1pt solid; PADDING-RIGHT: 0cm; BORDER-TOP: #d4d0c8; PADDING-LEFT: 0cm; PADDING-BOTTOM: 0cm; BORDER-LEFT: #d4d0c8; WIDTH: 24.45pt; PADDING-TOP: 0cm; BORDER-BOTTOM: #0b0d58 1pt solid; HEIGHT: 8.2pt; BACKGROUND-COLOR: transparent" vAlign=top width=33>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: center; mso-element: frame; mso-element-frame-hspace: 9.0pt; mso-element-wrap: around; mso-element-anchor-vertical: paragraph; mso-element-anchor-horizontal: page; mso-element-left: 333.05pt; mso-element-top: -106.3pt; mso-height-rule: exactly" align=center><SPAN style="FONT-SIZE: 12pt"><o:p><FONT face=Arial color=#000000>&nbsp;</FONT></o:p></SPAN></P></TD></TR></TBODY></TABLE></P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><SPAN style="FONT-SIZE: 10pt; COLOR: #0b0d58; FONT-FAMILY: Verdana; mso-fareast-font-family: Frutiger-Roman; mso-bidi-font-size: 12.0pt"><o:p><FONT color=#000000>&nbsp;</FONT></o:p></SPAN></P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt">&#10;<TABLE class=MsoNormalTable style="MARGIN: auto auto auto 0.5pt; BORDER-COLLAPSE: collapse; mso-table-layout-alt: fixed; mso-padding-alt: 0cm 0cm 0cm 0cm" cellSpacing=0 cellPadding=0 border=0>&#10;<TBODY>&#10;<TR style="HEIGHT: 18.9pt; mso-yfti-irow: 0">&#10;<TD style="BORDER-RIGHT: #d4d0c8; PADDING-RIGHT: 0cm; BORDER-TOP: #0b0d58 1pt solid; PADDING-LEFT: 0cm; BACKGROUND: #0b0d58; PADDING-BOTTOM: 0cm; BORDER-LEFT: #0b0d58 1pt solid; WIDTH: 168.45pt; PADDING-TOP: 0cm; BORDER-BOTTOM: #d4d0c8; HEIGHT: 18.9pt" vAlign=top width=225>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><FONT color=#000000><B><SPAN style="COLOR: white; FONT-FAMILY: Verdana">Asian or Asian British</SPAN></B><SPAN style="FONT-SIZE: 12pt"><o:p></o:p></SPAN></FONT></P></TD>&#10;<TD style="BORDER-RIGHT: #0b0d58 1pt solid; PADDING-RIGHT: 0cm; BORDER-TOP: #0b0d58 1pt solid; PADDING-LEFT: 0cm; BACKGROUND: #0b0d58; PADDING-BOTTOM: 0cm; BORDER-LEFT: #d4d0c8; WIDTH: 22.3pt; PADDING-TOP: 0cm; BORDER-BOTTOM: #d4d0c8; HEIGHT: 18.9pt" vAlign=top width=30>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: center" align=center><SPAN style="FONT-SIZE: 12pt"><o:p><FONT face=Arial color=#000000>&nbsp;</FONT></o:p></SPAN></P></TD></TR>&#10;<TR style="HEIGHT: 24.15pt; mso-yfti-irow: 1">&#10;<TD style="BORDER-RIGHT: #d4d0c8; PADDING-RIGHT: 0cm; BORDER-TOP: #d4d0c8; PADDING-LEFT: 0cm; PADDING-BOTTOM: 0cm; BORDER-LEFT: #0b0d58 1pt solid; WIDTH: 168.45pt; PADDING-TOP: 0cm; BORDER-BOTTOM: #d4d0c8; HEIGHT: 24.15pt; BACKGROUND-COLOR: transparent" vAlign=top width=225>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><FONT color=#000000><B><SPAN style="FONT-SIZE: 8pt; COLOR: #0b0d58; FONT-FAMILY: Verdana">Indian</SPAN></B><SPAN style="FONT-SIZE: 12pt"><o:p></o:p></SPAN></FONT></P></TD>&#10;<TD style="BORDER-RIGHT: #0b0d58 1pt solid; PADDING-RIGHT: 0cm; BORDER-TOP: #d4d0c8; PADDING-LEFT: 0cm; PADDING-BOTTOM: 0cm; BORDER-LEFT: #d4d0c8; WIDTH: 22.3pt; PADDING-TOP: 0cm; BORDER-BOTTOM: #d4d0c8; HEIGHT: 24.15pt; BACKGROUND-COLOR: transparent" vAlign=top width=30>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: center" align=center><FONT face=Arial><FONT color=#000000><B><SPAN style="FONT-SIZE: 16pt; COLOR: #0b0d58; mso-no-proof: yes">&#9633;</SPAN></B><SPAN style="FONT-SIZE: 12pt"><o:p></o:p></SPAN></FONT></FONT></P></TD></TR>&#10;<TR style="HEIGHT: 24.15pt; mso-yfti-irow: 2">&#10;<TD style="BORDER-RIGHT: #d4d0c8; PADDING-RIGHT: 0cm; BORDER-TOP: #d4d0c8; PADDING-LEFT: 0cm; PADDING-BOTTOM: 0cm; BORDER-LEFT: #0b0d58 1pt solid; WIDTH: 168.45pt; PADDING-TOP: 0cm; BORDER-BOTTOM: #d4d0c8; HEIGHT: 24.15pt; BACKGROUND-COLOR: transparent" vAlign=top width=225>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><FONT color=#000000><B><SPAN style="FONT-SIZE: 8pt; COLOR: #0b0d58; FONT-FAMILY: Verdana">Pakistani</SPAN></B><SPAN style="FONT-SIZE: 12pt"><o:p></o:p></SPAN></FONT></P></TD>&#10;<TD style="BORDER-RIGHT: #0b0d58 1pt solid; PADDING-RIGHT: 0cm; BORDER-TOP: #d4d0c8; PADDING-LEFT: 0cm; PADDING-BOTTOM: 0cm; BORDER-LEFT: #d4d0c8; WIDTH: 22.3pt; PADDING-TOP: 0cm; BORDER-BOTTOM: #d4d0c8; HEIGHT: 24.15pt; BACKGROUND-COLOR: transparent" vAlign=top width=30>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: center" align=center><FONT face=Arial><FONT color=#000000><B><SPAN style="FONT-SIZE: 16pt; COLOR: #0b0d58; mso-no-proof: yes">&#9633;</SPAN></B><SPAN style="FONT-SIZE: 12pt"><o:p></o:p></SPAN></FONT></FONT></P></TD></TR>&#10;<TR style="HEIGHT: 24.15pt; mso-yfti-irow: 3">&#10;<TD style="BORDER-RIGHT: #d4d0c8; PADDING-RIGHT: 0cm; BORDER-TOP: #d4d0c8; PADDING-LEFT: 0cm; PADDING-BOTTOM: 0cm; BORDER-LEFT: #0b0d58 1pt solid; WIDTH: 168.45pt; PADDING-TOP: 0cm; BORDER-BOTTOM: #d4d0c8; HEIGHT: 24.15pt; BACKGROUND-COLOR: transparent" vAlign=top width=225>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><FONT color=#000000><B><SPAN style="FONT-SIZE: 8pt; COLOR: #0b0d58; FONT-FAMILY: Verdana">Bangladeshi</SPAN></B><SPAN style="FONT-SIZE: 12pt"><o:p></o:p></SPAN></FONT></P></TD>&#10;<TD style="BORDER-RIGHT: #0b0d58 1pt solid; PADDING-RIGHT: 0cm; BORDER-TOP: #d4d0c8; PADDING-LEFT: 0cm; PADDING-BOTTOM: 0cm; BORDER-LEFT: #d4d0c8; WIDTH: 22.3pt; PADDING-TOP: 0cm; BORDER-BOTTOM: #d4d0c8; HEIGHT: 24.15pt; BACKGROUND-COLOR: transparent" vAlign=top width=30>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: center" align=center><FONT face=Arial><FONT color=#000000><B><SPAN style="FONT-SIZE: 16pt; COLOR: #0b0d58; mso-no-proof: yes">&#9633;</SPAN></B><SPAN style="FONT-SIZE: 12pt"><o:p></o:p></SPAN></FONT></FONT></P></TD></TR>&#10;<TR style="HEIGHT: 15.4pt; mso-yfti-irow: 4">&#10;<TD style="BORDER-RIGHT: #d4d0c8; PADDING-RIGHT: 0cm; BORDER-TOP: #d4d0c8; PADDING-LEFT: 0cm; PADDING-BOTTOM: 0cm; BORDER-LEFT: #0b0d58 1pt solid; WIDTH: 168.45pt; PADDING-TOP: 0cm; BORDER-BOTTOM: #d4d0c8; HEIGHT: 15.4pt; BACKGROUND-COLOR: transparent" vAlign=top width=225>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><FONT color=#000000><B><SPAN style="FONT-SIZE: 8pt; COLOR: #0b0d58; FONT-FAMILY: Verdana">Any other Asian background (please specify):</SPAN></B><SPAN style="FONT-SIZE: 12pt"><o:p></o:p></SPAN></FONT></P></TD>&#10;<TD style="BORDER-RIGHT: #0b0d58 1pt solid; PADDING-RIGHT: 0cm; BORDER-TOP: #d4d0c8; PADDING-LEFT: 0cm; PADDING-BOTTOM: 0cm; BORDER-LEFT: #d4d0c8; WIDTH: 22.3pt; PADDING-TOP: 0cm; BORDER-BOTTOM: #d4d0c8; HEIGHT: 15.4pt; BACKGROUND-COLOR: transparent" vAlign=top width=30>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: center" align=center><SPAN style="FONT-SIZE: 12pt"><o:p><FONT face=Arial color=#000000>&nbsp;</FONT></o:p></SPAN></P></TD></TR>&#10;<TR style="HEIGHT: 15.4pt; mso-yfti-irow: 5">&#10;<TD style="BORDER-RIGHT: #d4d0c8; PADDING-RIGHT: 0cm; BORDER-TOP: #d4d0c8; PADDING-LEFT: 0cm; PADDING-BOTTOM: 0cm; BORDER-LEFT: #0b0d58 1pt solid; WIDTH: 168.45pt; PADDING-TOP: 0cm; BORDER-BOTTOM: #d4d0c8; HEIGHT: 15.4pt; BACKGROUND-COLOR: transparent" vAlign=top width=225>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><SPAN style="FONT-SIZE: 12pt"><o:p><FONT face=Arial color=#000000>&nbsp;</FONT></o:p></SPAN></P></TD>&#10;<TD style="BORDER-RIGHT: #0b0d58 1pt solid; PADDING-RIGHT: 0cm; BORDER-TOP: #d4d0c8; PADDING-LEFT: 0cm; PADDING-BOTTOM: 0cm; BORDER-LEFT: #d4d0c8; WIDTH: 22.3pt; PADDING-TOP: 0cm; BORDER-BOTTOM: #d4d0c8; HEIGHT: 15.4pt; BACKGROUND-COLOR: transparent" vAlign=top width=30>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: center" align=center><SPAN style="FONT-SIZE: 12pt"><o:p><FONT face=Arial color=#000000>&nbsp;</FONT></o:p></SPAN></P></TD></TR>&#10;<TR style="HEIGHT: 9.05pt; mso-yfti-irow: 6; mso-yfti-lastrow: yes">&#10;<TD style="BORDER-RIGHT: #d4d0c8; PADDING-RIGHT: 0cm; BORDER-TOP: #d4d0c8; PADDING-LEFT: 0cm; PADDING-BOTTOM: 0cm; BORDER-LEFT: #0b0d58 1pt solid; WIDTH: 168.45pt; PADDING-TOP: 0cm; BORDER-BOTTOM: #0b0d58 1pt solid; HEIGHT: 9.05pt; BACKGROUND-COLOR: transparent" vAlign=top width=225>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"><SPAN style="FONT-SIZE: 12pt"><o:p><FONT face=Arial color=#000000>&nbsp;</FONT></o:p></SPAN></P></TD>&#10;<TD style="BORDER-RIGHT: #0b0d58 1pt solid; PADDING-RIGHT: 0cm; BORDER-TOP: #d4d0c8; PADDING-LEFT: 0cm; PADDING-BOTTOM: 0cm; BORDER-LEFT: #d4d0c8; WIDTH: 22.3pt; PADDING-TOP: 0cm; BORDER-BOTTOM: #0b0d58 1pt solid; HEIGHT: 9.05pt; BACKGROUND-COLOR: transparent" vAlign=top width=30>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: center" align=center><SPAN style="FONT-SIZE: 12pt"><o:p><FONT face=Arial color=#000000>&nbsp;</FONT></o:p></SPAN></P></TD></TR></TBODY></TABLE></P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt">&nbsp;</P>&#10;<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt"></o:p></SPAN></SPAN></o:p></SPAN><SPAN style="FONT-SIZE: 10pt; 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