BikeWhisperer LLC

BikeWhisperer LLC – Learn to Ride Participant Liability Waiver & Medical Release

THIS FORM MUST BE READ, COMPLETED IN FULL, SIGNED AND GIVEN OR SUBMITTED ONLINE TO THE BIKE WHISPERER INSTRUCTOR BEFORE THE PARTICIPANT MAY GO ON THE OUTING. EXPRESS ASSUMPTION OF RISK, RELEASE, INDEMNIFICATION AND COVENANT NOT TO SUE AGREEMENT.

In consideration for the services of BIKE WHISPERER LLC, its directors, officers, agents, and instructors (collectively referred to herein as "BW"), I, on behalf of myself and/or as the parent or guardian of the minor child participating in the BW activity, and our heirs, agree as follows: I understand and am aware that I understand and am aware that bicycle riding and related training activities (including the use of BW equipment such as bicycles, helmets, and protective gear), (referred to herein as "Activity"), are HAZARDOUS ACTIVITIES involving INHERENT AND OTHER RISKS of injury to any and all parts of the body. I further understand that injuries in the Activity are a COMMON AND ORDINARY OCCURRENCE, and I have made a voluntary choice for myself and/or the minor child listed below to ACCEPT AND ASSUME ALL RISKS OF INJURY OR DEATH that might be associated with or result from this Activity.

I understand that by signing this form, I am giving up certain legal rights, to the fullest extent allowed by law, I agree to RELEASE FROM LIABILITY, and to INDEMNIFY AND HOLD HARMLESS BW from any and all liability on account of, or in any way resulting from, personal injuries, death or property damage, in any way connected with this Activity. I further AGREE NOT TO MAKE A CLAIM OR SUE FOR INJURIES OR DAMAGES RELATING TO THIS ACTIVITY, even if caused by their NEGLIGENCE.

I understand and agree that this Agreement is intended to be as broad and inclusive as is permitted by law, and if any portion is held invalid, the balance shall continue in full legal force and effect. I agree that no oral representations, statements or inducements apart from this Agreement have been made.

AUTHORIZATION FOR FIRST AID AND MEDICAL TREATMENT

I recognize that medical or dental care may be necessary for myself and/or my minor child. I AUTHORIZE BW AND THE INSTRUCTOR(S) TO RENDER FIRST AID OR EMERGENCY CARE, within the scope of the certification of the instructor(s). In addition, I authorize BW to call for medical or dental care for myself and/or my minor child if, in the opinion of BW, medical or dental care is needed. I AGREE TO PAY FOR ALL EXPENSES AND COSTS ASSOCIATED WITH SUCH CARE AND RELATED TRANSPORTATION. In addition, I hereby authorize and consent for any x-ray examination, anesthetic, medical, dental or surgical diagnosis rendered under the general or special supervision of any member of the medical staff and/or emergency staff and/or dentist currently licensed by the state in which treatment is given and the staff of any acute general hospital holding a current license to operate a hospital from the State of New York Department of Public Health or the equivalent agency in another state. It is understood that this authorization is given in advance of any specific diagnosis, treatment, or hospital care being required but is given to provide authority and power to render care which the physician in the exercise of his best judgment may deem advisable. It is understood, medical condition allowing, that effort shall be made to consult the undersigned prior to rendering the treatment to the patient, but that any of the above treatment will not be withheld if the undersigned is incapacitated or cannot be reached.

PARTICIPANT'S INFORMATION

Participant Name - Rider 1

First NameLast Name

Birth Date Rider 1

MonthDayYear

Height in Inches

If a minor, Parent's/Guardian's Name (of minor participant)

First NameLast Name

Email

Mobile Number

Area CodePhone Number

MEDIA & USE OF NAME: To accomplish our goals, Trips for Kids Metro New York frequently sends press releases and photographs to the media (newspaper, radio, television and the internet) and uses photos in our own publications. It is the right of the individual whether or not to consent to the use of his/her photograph and/or name for the above publicity purposes. Unless otherwise stated, I hereby authorize Trips for Kids to use any photos taken of me and/or my minor child during Trips for Kids Metro New York’s activities.

PARTICIPANT'S EMERGENCY MEDICAL INFORMATION

List all medical conditions of which the outing leader should be aware or which may affect the participant's ability to participate in activities (such as asthma, heart disease, diabetes or neuromuscular or skeletal impairment):

Write "None" if No medical conditions

List the One persons to call in case of an emergency. We will try to contact them in the order that they are listed below.

Emergency Contact

First NameLast Name

Phone Number

Area CodePhone Number

I HEREBY ACKNOWLEDGE THAT ALL THE INFORMATION I HAVE PROVIDED in this electronic Document OF THIS AGREEMENT IS TRUE, CORRECT AND COMPLETE. I HEREBY ACKNOWLEDGE THAT I HAVE FULLY READ, UNDERSTOOD AND ACCEPTED EACH OF THE ABOVE PROVISIONS, AND VOLUNTARILY SIGNED THIS AGREEMENT. *Checking the Box below is the same as signing the document.