Build A Bike Workshop Registration

Build A Bike Workshop Registration

Please complete the form below to register and pay for this workshop series. NOTE: You will receive a confirmation email about enrollment in this particular series of dates. This form will be used throughout the year to build workshops from interested families.
Participant Name*

First NameLast Name
Parent Name*

First NameLast Name
Parent E-mail*
example@example.com
Participant Age*
This workshop is for ages 12 - 17
How did you hear about the workshop?*

Social mediaFriend/ColleagueShift Community CyclesNews/media storyPoster or flyer
Build A Bike Workshop participants must attend all workshop dates to complete the Build A Bike program. Classes will occur each Tuesday night from 6 PM - 7:30 PM on the following dates:
- October 7, 2025
- October 14, 2025
- October 21, 2025
- October 28, 2025
Can you attend all workshop dates?*

YesNo
What is your child's height?*
This helps us choose the right size of bike for them
Dinner will be provided. Please use this space to let us know of any dietary restrictions to be aware of: *

Liability and Media Release Forms
Please check only ONE box below. *Please note: opting out will not effect your child/ward's opportunity to participate in any of our activities.* I, FOR MYSELF, MY SPOUSE/PARTNER/CO-PARENT/CO-GUARDIAN, AND CHILD/WARD, HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT WE HAVE GIVEN UP RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.*

I give consent to having my child photographed and/or interviewed by news media and/or their likeness used marketing/messaging in relation to Shift Community Cycles Summer Camp.I DO NOT consent to having my child photographed and/or interviewed by news media and/or their likeness used marketing/messaging in relation to Shift Community Cycles Summer Camp.
RELEASE OF LIABILITY FOR MINOR PARTICIPANTS - READ BEFORE SIGNING

IN CONSIDERATION OF my child/ward being allowed to participate in any way in Shift Community Cycles Build A Bike Workshop; and their related events and activities, the undersigned acknowledges, appreciates, and agrees that:

The risks of injury and/or exposure to potential illness to my child from the activities involved in these programs are significant, including the potential for permanent disability and death, and while particular rules, equipment, and personal discipline may reduce these risks, the risks of injury and illness do still exist; and,

1. For myself, spouse/partner/co-parent/co-guardian, and child, I knowingly and freely assume all such risks, both known and unknown, even if arising from the negligence of the releases or others, and assume full responsibility for my child’s participation; and,

2. I willingly agree to comply with the program’s stated and customary terms and conditions for participation. If I observe any unusual significant concern in my child’s readiness for participation and/or in the program itself, I will remove my child from the participation and bring such attention of the nearest official immediately; and,

3. I myself, my spouse/partner, my child, and on behalf of my/our heirs, assigns, personal representatives and next of kin, HEREBY RELEASE AND HOLD HARMLESS Shift Community Cycles; its directors, officers, officials, agents, employees, volunteers, other participants, sponsoring agencies, sponsors, advertisers, and if applicable, owners and lessors of premises used to conduct the event (“Releasees”), WITH RESPECT TO ANY AND ALL INJURY, ILLNESS, DISABILITY, DEATH, or loss or damage to person or property incident to my child’s involvement or participation in these programs, WHETHER ARISING FROM THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE, to the fullest extent permitted by law.

4. I, for myself, my spouse/partner, my child, and on behalf of my/our heirs, assigns, personal representatives and next of kin, HEREBY INDEMNIFY AND HOLD HARMLESS all the above Releasees from any and all liabilities incident to my involvement or participation in these programs, EVEN IF ARISING FROM THEIR NEGLIGENCE, to the fullest extent permitted by law.

5. I, the parent/guardian, assert that I have explained to my child/ward: the risks of the activity, his/her responsibilities for adhering to the rules and regulations, and that my child/ward understands this agreement.

I, FOR MYSELF, MY SPOUSE/PARTNER/CO-PARENT/CO-GUARDIAN, AND CHILD/WARD, HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT WE HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.
Signature*

Clear

Payment
Prices for the Build A Bike Workshop are based on what you can pay. Please do not let finances be a deterrent to participation. We appreciate the generous support of those who are able to pay, and look forward to welcoming all interested participants. Scholarships are available for Build A Bike workshops.
Is your family eligible for OHP, SNAP, or subsidized housing? Scholarships are available for answering "yes." Documentation is required.*

YesNo

My Products

Frame - Full PriceFull cost for a brand new bike, mechanics instruction, food and associated workshop activities.

$400.00 Quantity

Gear - DiscountDiscounted cost for brand new bike, mechanics instruction, food and associated workshop activities.

$200.00 Quantity

ScholarshipPlease email Ari@shiftcc.org for more information on scholarship options.

$20.00 Quantity

Total

$0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

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Build A Bike Workshop Registration

Liability and Media Release Forms

Payment