BREAK THE CYCLE PARTICIPATION WAIVER – BTC Jr.

I, _____________________________ the parent or legal guardian of __________________________

born on ________________, ______; certify and affirm that I have been completely and thoroughly informed that as a child attending rides both  for training purposes and/or for recreational purposes with Break-n The Cycle Nonprofit Corp (“Break the Cycle”), my child will participate in certain activities which carry with them a degree of risk and danger. I acknowledge and understand that Break the Cycle may offer other activities not listed above that present similar risks or dangers to my child. 

I consent to my child’s participation in these activities. I acknowledge and understand that this PARENTAL AUTHORIZATION, CONSENT AND RELEASE has the same force and effect regardless of whether the activities engaged in are free or if a fee is charged. Further, I personally assume, on my child’s behalf, all risks in connection with said activities for any harm, injury or damages that may befall my child as a result of my child’s participation in the activities, whether foreseen or unforeseen, and still wish to allow my child to proceed with the activities.

In consideration of my child being allowed to participate in these activities, use various facilities, and use equipment and a bicycle, whether provided by Break the Cycle or myself, as a part of their participation with Break the Cycle, on behalf of my child, I hereby voluntarily release, forever discharge, and agree to indemnify and hold harmless Break the Cycle from any and all claims, demands, or causes of action, which are in any way connected with my child’s participation in these activities or use of Break the Cycle or designated destination’s, equipment and facilities.

I understand that it is my obligation to inform Break the Cycle of any and all health considerations or medical

conditions that would restrict my child’s participation in any and all activities while participating with

Break the Cycle. I recognize and acknowledge that my child’s participation in activities despite such medical conditions is done with my full consent and at my own risk, on behalf of my child. Should the need for medical attention arise, Break the Cycle will attempt to contact me as soon as practical under the circumstances. 

In cases of emergency, I further consent to the examination or treatment of my child by a physician duly licensed to practice medicine in the United States of America or any health care professional duly licensed to provide health care services in the United States of America for medical care and services deemed necessary by the doctor, its agents, servants, and employees. 

I give permission to the doctor or health care professional to provide any and all medical care they deem, in their professional opinion, to be necessary. I agree to pay for any and all medical expenses incurred as a result of the use of this consent. 

I acknowledge by signing this document, that if anyone is hurt or property is damaged during my child’s participation in these activities, I may be found by a court of law to have waived my right to maintain a lawsuit against Break the Cycle on the basis of any claim from which I have released them herein. I agree that if any portion of this agreement is found to be void or unenforceable, the remaining portions remain in full force and effect. I have fully informed myself of the contents of this PARENTAL AUTHORIZATION, CONSENT AND RELEASE by reading it before signing it.