Sequim Wheelers Liability Waiver

Name*

First NameLast Name

Phone Number*

Please enter a valid phone number.

Email

example@example.com

Waiver:

1) I acknowledge there are risks involved in participating in cycling activities, such as road hazards, potholes, traffic, and weather conditions. I understand we may be riding on streets where motor vehicles are present.

2) I agree to follow Sequim Wheelers’ rules for safety and agree not to hold it or its officers, affiliates, or volunteers liable for injury as a result of my activities with Sequim Wheelers.

3) The named individual must be able to get seated on the trike on their own or with assistance from a qualified person assigned to help them with transfers (e.g. family member, caregiver). Sequim Wheelers volunteers are not qualified to physically assist in any transfer process. If qualified assistance is not provided, no ride may be given.

Weight Limit:*

Emergency Contact Name:*

First NameLast Name

Emergency Contact Phone:*

Please enter a valid phone number.

Emergency Contact Alternate Phone:

Please enter a valid phone number.

Emergency Contact Relationship:*

Signature and Media Consent
I understand that delivering an electronic signature in the signature field below will have the same effect as an original manual paper signature. The electronic signature will be equally as binding as an original paper signature.

Electronic Signature*

First NameLast Name

Date*

Date

By providing my initials below, I give permission to Sequim Wheelers to use my images, voice, or words for the purpose of promoting its mission of giving free rides to those who cannot ride on their own.

Media Consent Initials:

Initials

Sequim Wheelers' Liability Waiver