CWA-B Registration & Waiver (v26.1)

CWA-B Registration & Waiver Form
Cycling Without Age - Brockville
If a passenger is their own Legal Decision Maker they must complete and sign this waiver as a Passenger.

If a passenger has a Legal Decision Maker or Power of Attorney then all fields must be completed and the waiver signed by the LDM or POA on behalf of the passenger.
Person completing this waiver is a:
First Name
Last Name
Phone Number
Format: (000) 000-0000.
email
example@example.com
Residence
Other Address
Only required when Residence is "Other"
Optional Notes
Emergency Contact Details
Enter a contact person name and phone number or a LTC residence
Legal Decision Maker Name
Legal Decision Maker Contact Info
It is the responsibility of the Passenger or LDM to request a Helmet
I acknowledge that participation in the Cycling Without Age -Brockville program involves being a passenger in a 3 wheeled vehicle piloted by volunteers.
I acknowledge that participation in this activity could involve the possibility of injury.
I accept these risks, and all others arising from participation in Cycling Without Age.
I hereby voluntarily release, forever discharge, and agree to indemnify and hold harmless Cycling Without Age - Brockville from any and all claims, demands, or cause of action, which are in any way connected with participation in this activity.
I consent to being photographed, videotaped or interviewed in order to help raise awareness about Cycling Without Age – Brockville.
Date

MonthDayYear
Date
Signature
Person submitting this form
GeoStamp
Should be Empty:

CWA-B Registration & Waiver Form

Cycling Without Age - Brockville