Trishaw Rider Application

Trishaw Passenger Application

We are pleased you are interested in taking a ride on the Sebastopol Area Senior Center's Trishaw! Please complete this application and we will get back to you as soon as possible.
Passenger Information
Name*

First NameLast Name
Sex
Date of Birth*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
If someone will be accompanying the passenger, please add their name.

First NameLast Name
Relationship to passenger:
Spouse, sibling, friend etc
Birth Date

MonthDayYear
Passenger Health/Mobility Questions

Check all that apply.
Needs assistance walking*
Uses walker*
Uses wheelchair or scooter*
Hearing Impaired*
Trouble understanding or following directions*
Any known medical conditions that might make it unsafe to ride in the trishaw (eg. inability to momentarily stand for transfer to trishaw, inability to sit upright with seatbelt only, recent stroke or heart attack, history of seizures, recent loss of consciousness, vertigo, or motion sickness): *
Emergency Contact Name
Emergency Contact Phone
Emergency Contact Relation
Waiver of Liability

I the undersigned, am the passenger named herein taking part in Sebastopol Area Senior Center’s Cycling Without Age Sebastopol Program as a passenger: 1. I understand and agree that there are inherent risks associated with participation in this activity, that my participation is voluntary and that I am physically fit enough to participate in the activity. 2. I accept all responsibility for my participation including the possibility of personal injury, death, property damage of any kind notwithstanding that the injury, loss may have been contributed to or occasioned by the negligence of Sebastopol Area Senior Center and its officers, directors, employees, volunteers, members, agents, assigns, legal representative and successors. 3. I do hereby indemnify and hold harmless Sebastopol Area Senior Center, 167 North High Street, Sebastopol, CA and its officers, directors, employees, volunteers, members, agents, assigns, legal representatives and successors and any and all business associates and partners involved in the above noted activity and each of them, their owners, officers, employees and volunteers, hereby waiving all claims for damage now or in the future arising from any loss, accident, injury or death which may be caused by or arise from participation of the individual named herein during this event; and agree to assume all risks for the activity noted above that the individual named herein has agreed to participate in. My signature acknowledges that I am over the age of 18 and had sufficient time to read and understand this waiver. I have had the opportunity to seek my own legal advice and that I understand and agree to the conditions stated in this document and that they are binding on my heirs, next of kin, executors, administrators and successors.
Weight Disclosure

Note: We encourage passengers to ride with friends and family members, however, the trishaw has a passenger limit of 350 pounds. If both passengers exceed the weight limit, the accompanying family member/friend may bike behind the trishaw. We have assistant pilots who can sit next to the passenger if requested.
Approximate weight of main passenger*
Approximate weight of accompanying passenger, if applicable.
Signature of Passenger*

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Signature of accompanying passenger, if applicable.

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Trishaw Passenger Application

Passenger Information

Passenger Health/Mobility Questions

Waiver of Liability

Weight Disclosure