Passenger Waiver
This form to be completed by Pilot for every passenger prior to the ride.
Cycling Without Age - Mississauga
Participant registration, contact and waiver information
Passenger Name
*
First Name
Last Name
Passenger telephone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Describe your mobility
*
Completely mobile
Can stand and sit unaided
Require a cane
Require a walker
Require a wheelchair
Need assistance from facility personnel
Require a companion
Require portable oxygen
Other
Approximate Weight
Maximum combined passenger weight should be less than 250lb
All rides currently start from Tall Oaks Park in Port Credit. The pick up/drop off location will be 44 Elmwood Ave. S. Please select your home residence from the menu or add location below:
Please Select
Port Credit Lakeshore Verve
Parkland on the Glen, Glen Erin
Chartwell Robert Speck Pkwy
Credit River Residence Verve
Please select one or enter an alternative below:
Alternative location
Facility and address
Do you have any back/spinal issues that may be exacerbated by bumps on the ride?
No
Yes
Other
Decision to wear a helmet
Please Select
Agree
Decline
Helmet and single use hair net provided.
Emergency Contact
*
First Name
Last Name
Emergency Contact Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Guardian or Power of Attorney
First Name
Last Name
Relationship to Passenger
I acknowledge that my participation in the CyclingWithout Age - Mississauga program involves being a passenger in a trishaw piloted by volunteers.
*
Acknowledge
I acknowledge that my participation in this activity could involve the possibility of injury.
*
Acknowledge
I accept these risks, and all others arising from my participation in Cycling Without Age.
*
Acknowledge
I hereby voluntarily release, forever discharge, and agree to indemnify and hold harmless Cycling Without Age - Mississauga from any and all claims,demands, or cause of action, which are in any way connected with my participation in this activity.
*
Acknowledge
I consent to being photographed, videotaped or interviewed in order to help raise awareness about Cycling Without Age - Mississauga
*
Consent
Date
-
Month
-
Day
Year
Date
Time
Hour Minutes
AM
PM
AM/PM Option
Signature of Passenger or Power of Attorney
*
Continue
Continue
Should be Empty: