Cycle Therapy Racing Inc. — Pedal to the Mental™ Summer Camp Buckley 2026
This waiver covers Pedal to the Mental™ Summer Camp in Buckley, Washington, held every Wednesday from June 24, 2026 through August 26, 2026. Any youth or adult rider using a Cycle Therapy Racing loaner bicycle or helmet must have a completed waiver on file before participating. This waiver is intended to cover the full Buckley Wednesday camp season, unless revoked or replaced by Cycle Therapy Racing.
Rider Information
Cycle Therapy Racing Inc. | info@cycletherapyracing.org | 206-949-3236 | www.cycletherapyracing.org
Rider Full Name
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First Name
Middle Initial
Last Name
Date of Birth
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Month
-
Day
Year
Date
Age
Rider Type
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Minor
Adult
Parent/Guardian Information and Consent
Parent/Guardian Full Name
*
First Name
Middle Name
Last Name
Relationship to Rider
*
Please Select
Parent
Legal Guardian
Step-Parent
Grandparent
Foster Parent
Other
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Minors must have a parent or legal guardian complete and sign this form. If the rider is under 18, a parent/guardian must complete the Parent/Guardian Information and provide the Parent/Guardian Consent acknowledgment and signature. Adult riders (18 and older) may complete and sign for themselves.
Parent/Guardian Consent
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I certify that I am the parent or legal guardian of the minor participant listed on this form. I give permission for my child to participate in Pedal to the Mental™ Summer Camp Buckley 2026 activities and to use Cycle Therapy Racing loaner equipment if applicable. I understand the risks described in this waiver and agree to the release, assumption of risk, emergency medical authorization, code of conduct, and all other acknowledgments on behalf of my child.
Adult Participant Consent
*
I certify that I am 18 years of age or older and voluntarily agree to participate in the activities covered by this waiver.
Email Address
*
example@example.com
Emergency and Medical Information
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Medical Conditions, Allergies, and Medications(If none write "none")
Emergency Care Permission if Contact Cannot Be Reached
*
Yes, I authorize emergency care
No, do not authorize emergency care
Camp Dates
This waiver covers all Wednesday Pedal to the Mental™ Summer Camp sessions in Buckley, Washington from June 24, 2026 through August 26, 2026. Signers do not need to select individual dates because this waiver applies to the entire Buckley summer camp season.
Loaner Equipment Checkout
Loaner bike and helmet checkout agreement
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Bike only
Helmet only
Both bike and helmet
No equipment
Additional Required Acknowledgments
The following acknowledgments support the waiver and release above by confirming that the signer understands specific safety, equipment, conduct, and information accuracy expectations.
Liability Release Parties
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I understand and agree that this waiver and release applies to Cycle Therapy Racing Inc., its board members, officers, directors, volunteers, coaches, ride leaders, staff, sponsors, donors, community partners, municipal partners, property owners, landowners, equipment donors, and affiliated organizations, to the fullest extent allowed by Washington law.
Activity Risks Acknowledged
*
I understand that cycling, BMX-style riding, bicycle skills instruction, group riding, and outdoor recreation involve inherent risks, including falls, collisions, loss of control, equipment or mechanical issues, uneven surfaces, obstacles, weather conditions, actions of other participants, injury, property damage, disability, or death.
Equipment Use and Return
*
If using Cycle Therapy Racing loaner equipment, I agree that the rider will use the bicycle, helmet, and related equipment responsibly, follow all safety instructions, wear a helmet while riding, report crashes or damage, and return equipment when requested. Detailed bike and helmet checkout is managed separately by Cycle Therapy Racing staff or volunteers.
Code of Conduct
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I agree that the rider will follow staff and volunteer instructions, ride safely, wear a helmet, respect other participants, avoid bullying or unsafe behavior, and respect the facility, equipment, and community. I understand that unsafe or disrespectful behavior may result in removal from activities.
Information Accuracy Confirmation
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I certify that the information provided on this form is true and accurate to the best of my knowledge. I understand that Cycle Therapy Racing relies on this information for safety, emergency contact, waiver, and participation purposes.
Waiver and release acknowledgments
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I understand bicycling, BMX-style riding, skills instruction, outdoor recreation, group riding, riding near other participants, falls, collisions, loss of control, uneven surfaces, weather, mechanical issues, and the actions of other participants all involve known and unknown risks
I assume all risks of participation to the fullest extent allowed by Washington law
I release and hold harmless Cycle Therapy Racing Inc. and its board members, officers, directors, volunteers, coaches, ride leaders, staff, sponsors, donors, community partners, municipal partners, property owners, landowners, equipment donors, and affiliated organizations to the fullest extent allowed by Washington law
If the rider is a minor, I am a parent or legal guardian and I consent to the minor’s participation
If the rider is 18 or older, I consent to my own participation
I understand that any rider, youth or adult, using a Cycle Therapy Racing loaner bike or helmet must have a completed waiver before participating
I authorize Cycle Therapy Racing staff or volunteers to seek emergency medical care if a parent/guardian or emergency contact cannot be reached, and I understand I am responsible for medical costs
I confirm I have read and understand this waiver, that it is a legal release, that the information I provided is accurate and complete, and that I have authority to sign for the minor participant if applicable
Optional photo/video/media permission
Yes, permission granted
No, do not use my image or video
Relationship to Rider (if minor)
*
Please Select
Parent
Legal Guardian
Step-Parent
Grandparent
Foster Parent
Other
Signature and Copy Delivery
Please have this waiver reviewed by Washington legal counsel before use.
Electronic Signature — Parent/Guardian for riders under 18, or Adult Participant if 18+
*
By signing, I confirm I have read and agree to this waiver. If the rider is under 18, I confirm I am the rider’s parent or legal guardian and have authority to sign on their behalf. If I am signing as an adult participant, I confirm I am 18 years of age or older.
Signer Full Name
*
First Name
Last Name
Date Signed
*
-
Month
-
Day
Year
Date
Email address for completed copy
*
The signer will receive a copy here.
Submit
Submit
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