EARN-A-BIKE @ VIDA University Health 6:15-7:15PM
NOTE*** PARTICIPANTS MUST ATTEND EACH SESSION TO RECEIVE A BIKE AND WE ASK PARENTS STAY ON SITE DURING CLASS *** PARENTS AND CHILD MUST ATTEND BIKE BUILD EVENT ON Saturday, October 24th (3 hour event) If you have any questions, please email Avery Stephens at avery@eabsa.org * Indicates required question
I understand that my child must attend all sessions to receive a bike. I also understand that my child and I will need to attend the Bike Build Event on Saturday, October 24th.
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I understand
Participant Full Name:
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Medical Conditions/Allergies:
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Age:
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7
8
9
10
11
12
Gender:
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Male
Female
Prefer not to say
Height: (PLEASE DO NOT GUESS. THIS IS HOW WE ENSURE YOUR CHILD RECEIVES THE CORRECT SIZE BIKE FOR THEIR HEIGHT)
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Weight:
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Grade:
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3rd
4th
5th
6th
7th
School Participant Attends:
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Does your child currently know how to ride a bike without training wheels?
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Yes
No
T-shirt Size:
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Youth XS
Youth S
Youth M
Youth L
Youth XL
Youth XXL
Adult S
Adult M
Adult L
Parent Name:
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Address:
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Zip Code:
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Phone Number:
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Email Address:
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Emergency Contact Name:
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Emergency Contact Number:
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By signing this form, I acknowledge to have read and agree to the Program Requirements and Safety Guidelines: -As a participant and parent, I understand that bicycle maintenance, repair and riding can be dangerous, and I will not hold the Earn-A-Bike, the volunteers, sponsors, or anyone associated with them, responsible for anything that may happen to me or my child while participating in any program or event. - In the case of an emergency, EAB volunteers have my permission to seek appropriate medical care for my child. - EAB may use photographs or videos of this program and event for any lawful purposes without further notice. -EAB is not responsible for lost or stolen items. No one should bring valuable items to the event, and especially not leave them unattended. -You must have any prescribed medicines or medical devices (such as asthma inhalers, glasses or seizure medicine) in your possession to participate. -Participants must not wear: sandals, untied shoes, skirts, baggy pants or hairstyles that can’t be worn with a helmet.
Participant Signature:
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Parent/Guardian Signature:
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Date:
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Letter of Commitment Student Commitment: I promise to abide by the Earn-A-Bike safety guidelines, rules, principles, and expectations of the Earn-A-Bike Healthy Living Program I promise to: -Sign and submit this commitment letter and registration form -Attend all Earn-A-Bike classes and stay until EAB class dismissal -Be on my best behavior during the Earn-A-Bike classes and Bike Build Event -Respect my teacher -Accept responsibility and the consequences for my personal behavior towards my teachers and fellow students -Attend the Earn-A-Bike Bike Build event with my parents in May
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Does the student acknowledge the consequences listed below if their personal behavior is deemed as innapropriate? AGGRESSIVE BEHAVIOR- (ex. hitting, biting, bullying, fighting, vulgar language or spitting)Incident 1: The parent will be notified immediately and this will be a warning.Incident 2: In the event of a second incident of aggressive behavior, the parent will be asked to remove their child for the remainder of the session. A parent consultation is required at this time as well.Incident 3: On the third occurrence of an aggressive behavior a meeting will be scheduled with the family to discuss the next possible steps to take, which could include loss of privileges of earning their bike.Student Signature:
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Parent Commitment I give permission for my child, to participate in the Earn-A-Bike Healthy Living program. I give permission to collect survey data from my child about empowerment, healthy eating, and physical activity. I promise to make the commitment to have my child attend all classes. I acknowledge that there will be Bike Build event on October 24, 2026, which I am required to attend in order for my child to receive their bike.
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Submit
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