Volunteer & Earn-a-Bike Interest Form

Emergency contact

First NameLast Name

Emergency phone number

Please enter a valid phone number.Format: (000) 000-0000.

If you are 18 or older, are you willing to complete a background check if required?

WAIVER

I Acknowledge that I understand the nature of Jack the Bike Man, Inc. sponsored Activities at and outside of Jack the Bike Man, Inc. (“Activities”) and warrant that I am qualified, in good health, and in proper physical condition to participate in such Activities.

I Acknowledge that some Activities occur on public roads and other facilities on which the risks of travel are to be expected and that some activities occur in a bike shop in which the risks of a shop setting are to be expected. These “RISKS” include MINOR INJURIES, SERIOUS BODILY INJURIES, PERMANENT DISABILITY, PARALYSIS AND DEATH. These Risks may be caused by my actions or inactions as well as the actions or inactions of others participating in the Activities.

I ACCCEPT AND ASSUME ALL RISKS FOR LOSSES, COSTS AND DAMAGES I incur as a result of my participation in any Activities including any and all economic or non-economic damages not known to me nor readily foreseeable at this time.

I RELEASE, COVENANT NOT TO SUE, and HOLD HARMLESS Jack the Bike Man, Inc., its administrators, directors, agents, officers, members, volunteers, and employees, other participants, or any sponsors (“Releases”) for any and all liability related to Activities caused or alleged to be caused in whole or in part by the Releases. I further agree that if, despite this release, I, or anyone on my behalf, make such claim against any of the Releases, I will indemnify and hold harmless the Releases from any and all costs they incur as the result of such claim including, but not limited to, attorney fees and costs.

In case of an emergency, I hereby authorize and give permission to any physician, hospital, health care provider, or other medical personnel selected by the staff of Jack the Bike Man, Inc. to provide prompt medical treatment and arrange necessary related transportation. I agree that once I am in the care of medical personnel or a medical facility, Jack the Bike Man, Inc. shall have no further responsibility me and I agree to pay all costs associated with such medical care and transportation. I agree to allow Jack the Bike Man, Inc. staff to dispense medications to me as needed.

It is my responsibility to ride and behave safely at all times. Practice safe work habits and safe riding habits. Always wear a helmet when riding to, from or on Jack the Bike Man, Inc. programs.

I understand that this is a Drug and Alcohol Free establishment and I will not be under the influence of any substances while here. I understand that I am subject to being drug tested if deemed appropriate.
I HAVE READ THIS AGREEMENT, FULLY UNDERSTAND ITS TERMS, AND AGREE TO IT.

Sign (must be 18 and over)

Volunteer & Earn-a-Bike Interest Form

Parent Guardian Information

Earn-a-Bike

Volunteer Emergency Information & Waiver