FALL 2024 Cycling Club

Blackstone Bicycle Works (BBW) is a free after-school and summer youth program of Experimental Station that teaches mechanics, bicycle advocacy, cycling, and workforce development to youths from disadvantaged communities on Chicago’s south side. Step up your game with our Youth Competitive Cycling Club, designed for ages 14-18! This club focuses on advanced training, technique improvement, and race preparation. Members will participate in regular training sessions, competitive events, and team strategy workshops. It's the perfect environment to push your limits, develop your skills, and compete at a higher level alongside a team of dedicated riders!

Fall Session: September 20th - December 13th (every Wednesday from 4-6pm).

We are now accepting registrations for the Fall session. Participants will work on advanced riding techniques, and learn about sports nutrition, and competitive cycling. Blackstone's program also integrates STEM (Science, Technology, Engineering, and Math) learning, food education, healthy snacks, cycling training, fun and interactive activities such as group bike rides (weather and daylight permitting), and field trips. To ensure hands-on learning and engagement, each session is limited to 10 participants. Participants are chosen based on registration date and alignment with BBW's mission, with priority given to participants who reside on the south side of Chicago and come from disadvantaged communities. We wish to create an inclusive community that focuses on youth from Woodlawn and surrounding neighborhoods. We welcome participants who feel underserved and who may have limited access to resources due to racial/ethnic identity, social/economic class, religion, gender identity and expression, disabilities, size, or sexual orientation. If you are not selected for this round of programming, you will be notified and placed on a waitlist. Please feel free to sign up again for the next round if that occurs. All information on this form is confidential. Some questions are required by our funders for continued support and other questions help BBW staff better serve our youth.

Incomplete registrations will not be accepted.

Are you a returning participant?*

Name of the participant (Youth's Name)*

First NameLast Name

Date of Birth of the Youth*

Date

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

What school does the participant attend?*

What grade is the participant in?*

9th Grade10th Grade11th Grade12th Grade

Sex/Gender Identity*

Race/Ethnicity*

Parent/Guardian Name*

First NameLast Name

Relationship to the participant?*

Phone Number *

Please enter a valid phone number.

Email*

example@example.com

Preferred Contact Method?*

EmailPhone

Medical Help- In the event of a serious injury or illness, may Blackstone Bicycle Works or Experimental Station staff seek immediate medical attention for the participant?*

YesNo

Medical Help Alternatives: If NO please specify what action we should take. In general, we will first attempt to contact a parent or guardian, then medical professionals.

Are any accommodations needed for the participant? Is there anything that you believe would be helpful for the counselors to know to enhance the experience of your child? (Accommodations will not be a basis for a child to not be selected).

Dietary Restrictions/Allergies - As a reminder, snacks will be provided.*

Liability Waiver:

In consideration of my participation in Blackstone Bicycle Works’ program, I, (PARTICIPANT) , agree to release and on behalf of myself, my heirs, representatives, executors, administrators, and assigns, HEREBY DO RELEASE the Experimental Station, an Illinois not-for-profit corporation D.B.A. Blackstone Bicycle Works, its officers, agents, and employees from any cause of action, claim, or demand of any nature whatsoever, including but not limited to, a claim of NEGLIGENCE, which I, my heirs, representatives, executors, administrators and assigns may now have, or have in the future against the Experimental Station, an Illinois not-for-profit corporation D.B.A. Blackstone Bicycle Works, on account of bodily injury, property damage, death or accident of any kind, or any other liability whatsoever, arising out of or in any way related to my participation in Blackstone Bicycle Works’ youth program, including, but not limited to, use of tools in the shop, bicycle field trips, and bicycle-related competitions. I hereby certify that I have full knowledge of the nature and extent of risks inherent in bicycling, including all manner of injury resulting from falling from a bicycle onto the concrete pavement, and that I am voluntarily assuming the risks. I understand that I will be solely responsible for any loss or damage, including loss of limb or death, which I sustain while participating in any of Blackstone Bicycle Works’ youth program activities, and that by this agreement, I am relieving the Experimental Station, an Illinois not-for-profit corporation D.B.A. Blackstone Bicycle Works of any liability for such loss, damage, or death. I have read this form and fully understand that by checking the box, I am giving up legal rights and/or remedies that may be available to me. I acknowledge that I have assumed responsibility and legal liability for the claims or other legal demands, including defense costs, which may be asserted by other third parties against me as a result of my participation in these activities.

Initial and Date*

Your initials and date count as a signature

Publicity Waiver OPTIONAL:

By typing my name and date, I give permission for my youth's picture and/or words to appear in Blackstone Bicycle Works or Experimental Station published and electronic materials and communications (such as newsletters, flyers, brochures or websites).If you wish to decline please type the word "decline" into the textbox instead. You will still be able to participate in our program even if you do not sign.

Initial and Date*

Your initials and date count as a signature

By signing this agreement, I understand and agree to the following terms:

1.  Authorization: I authorize   First Name   Last Name   [Student's/Participant's Name] to independently sign in upon arrival and sign out upon departure from the Summer Camp premises each day.

2.  Responsibility: I understand that it is my responsibility to ensure that my child arrives and departs the camp according to the designated schedule and that the camp's staff will not be held responsible for incidents occurring outside of camp hours.

3.  Emergency Contact: I will provide accurate emergency contact information to the camp, and I understand that the camp will contact me immediately in case of an emergency or if my child fails to arrive or depart as scheduled.

4.  Behavior and Compliance: I acknowledge that my child will follow all camp rules and regulations and will conduct themselves in a manner that is safe and respectful to others.

5.  Changes or Revocation: I understand that I may revoke this permission at any time by notifying the camp in writing.

6.  Liability Waiver: I acknowledge that while the camp will take all reasonable precautions for the safety and well-being of participants, they cannot be held liable for any accidents, injuries, or losses that may occur during the camp activities, including during the signing in and out process.

Initial and Date*

Your initials and date count as a signature