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CYCLE PERMIT

APPLICATION

PARENT

I wish to apply for my son:

Name: ........................................................... Tutor Group: ...................................................

To be issued with a bicycle permit. I understand that a condition of this permit being issued is that I

will comply with the conditions outlined in the attached Cycle Permit Protocol and that I fully

understand the consequences for failure to comply.

Signed: .......................................................... Date: ..............................................................

Parent/Carer

PUPIL

I ................................................................... agree to wear a bicycle helmet at all times when

cycling to and from school. I will ensure that my bicycle is roadworthy and is fitted with adequate front

and rear lights and I agree to cycle safely and in accordance with the Highway Code. I understand that

failure to comply with this agreement may result in my permit being withdrawn for a period of one

month. Any further non-compliance will result in a total loss of my permit.

Signed ........................................................... Date ...............................................................

When completed, please return this form to the School Office. Your bicycle permit will then

be issued to you.

FOR SCHOOL USE

Permit granted

Signed (AHT) .................................................. Date ...............................................................

Cc pupil file / pupil