Cycling Without Age Lanark County creates extraordinary experiences by providing trishaw rides for passengers piloted by volunteers.

I,   Passenger First Name*   Passenger Last Name*  , understand and agree that my participation in Cycling Without Age Lanark County, is conditional upon my execution of this document.

I hereby agree to indemnify and save Cycling Without Age Lanark County, harmless from all loss, cost, expense, judgement or damage on account of injury to persons including death or damage to property in anyway caused by the negligence of its servants, agents or employees related to or arising out of programs or other matters to which this agreement pertains, together with all legal expenses and costs incurred by Cycling Without Age Lanark County in defending any legal action pertaining to the above.

1. I acknowledge that my participation in the Cycling Without Age County program
involves being a passenger in a trishaw piloted by volunteers.

2. I acknowledge that my participation in bicycling activities, including trishaw rides as part of Cycling Without Age Lanark County, involves the possibility of injury, disability, paralysis, death or damage to myself, to property, or to third parties. The risks associated with bicycling and trishaw activities include, among other things: accidents involving other bicycles or vehicles; collision with fixed or movable objects; injuries or accidents involving contact with the trishaw; falls from the trishaw; the negligence of other operators of motor vehicles or myself; weather conditions; slipping and falling; falling objects; water hazards; exhaustion; exposure to
temperature and weather extremes which could cause hypothermia; hyperthermia (heat-related illnesses); heat exhaustion, sunburn, dehydration; and exposure to potentially dangerous wild animals; insect bites; and hazardous plant life; equipment failure; and improper lifting or carrying; my own physical condition, and the physical exertion associated with this activity; the condition of roads, terrain, or highways and accidents connected with their use.

3. I agree my participation in Cycling Without Age Lanark County activity is purely voluntary.

4. I accept these risks, and all others arising from my participation in Cycling Without Age, even if arising from the negligence, gross negligence or negligence rescue by those associated in any way with Cycling Without Age Lanark County, including their respective officers, directors, employees, agents, servants, volunteers and representatives (“releases”).

5. I understand that all applicable rules for participation must be followed and the sole responsibility for my personal safety remains with me, including my physical and emotional preparation and fitness to participate in bicycling activities, including Cycling Without Age Lanark County.

6. I understand and agree to remove myself from participation if I sense or observe any unusual hazard or unsafe condition, or if, at any time, I feel unable or unfit to safely continue for any reason.

7. I hereby voluntarily release, forever discharge, and agree to indemnify and hold harmless Cycling Without Age Lanark County from any and all claims, demands, or cause of action, which are in any way connected with my participation in this activity, including any such claims which allege negligent acts of Cycling Without Age Lanark County.

8. Should Cycling Without Age Lanark County or anyone acting on its behalf be required to incur attorneys’ fees and costs to enforce this agreement, I agree to indemnify and hold them harmless for all such fees and costs.

9. I further certify that I am willing to assume the risk of any medical or physical condition I may have.

I acknowledge that I have read and understood this Passenger Agreement and Assumption of Risks. I am aware that by signing this agreement I am waiving substantial legal rights, on my behalf and on behalf of my heirs, executors, administrators and next of kin, including giving up the right to sue Cycling Without Age Lanark County.

Passenger
Passenger First Name*   Passenger Last Name*   
Passenger Signature*      Date* 

Witness
Witness First Name*   Witness Last Name*  
Witness Signature*       Date*   

Emergency Contact Information   
Facility:    Please Select Stoneridge Manor, 29 Costello Drive, Carleton Place, Ontario K7C 0B4. 613-257-4355 Other *   

Emergency Contact Person:   First Name*   Last Name*    
Phone:   Area Code*   Phone Number*      

Personal Information  
This information is collected to allow the CWALC program to provide the best and safest level of service possible.

Please describe your mobility:    Please Select Completely mobile Can Walk Wheelchair Need assistance from facility to transfer *   
Are you able to stand up and sit down unassisted?   Yes   No*   
Are you able to sit up unaided?   Yes   No*  
Do you need a companion to ride with you?   Yes   No*    
Do you require oxygen?   Yes   No*   
Describe medical conditions or anything else that the volunteer pilot should know:      
       

Authorized Family Member or Legal Guardian’s Additional Identification

I   Authorized First Name*   Authorized Last Name*   have read and understood the above Passenger Agreement and Assumption of Risk agreement, and have discussed the same with the participant signing above (“Passenger”). I am satisfied the said Passenger understands the waiver and release and his/her obligations as set out. In consideration of the participation of the Passenger I too, agree to waiver, release and identify the Releases in the terms set out above. I am aware that by signing this agreement I am waiving substantial legal rights, which the Passenger and I, our respective heirs, executors, administrators and next of kin may have against the Releases.

Authorized First Name*   Authorized Last Name*   Relationship to passenger*   
Authorized Signature*   Date*   
 
MEDIA/PUBLICITY CONSENT FORM

To be completed by the passenger

From time to time some of our program participants have had the chance to take part
in activities that raise the profile of Cycling Without Age Lanark County in the
community.

I,   Passenger First Name*   Passenger Last Name*   hereby consent to be photographed,
videotaped, interviewed for radio, interviewed for television, interviewed for newspaper articles and for any other publication or medium, for raising awareness about the Cycling Without Age - Lanark County program. I understand that I,   Passenger First Name*   Passenger Last Name*   may be seen by the general public and clearly identified as a participant of the Cycling Without Age Lanark County program.

To be completed by the authorized family member or legal guardian

As the family member or legal guardian, I,   Authorized First Name*   Authorized Last Name*   (Family member or legal guardian) give consent for   Passenger First Name*   Passenger Last Name*   (Passenger) to be photographed, videotaped, interviewed for radio, interviewed for television, interviewed for newspaper articles and for any other publication or medium, for the purpose of raising the awareness of Cycling Without Age Lanark County. I understand that   Passenger First Name*   Passenger Last Name*   (Participant) may be seen by the general public and clearly identified as a participant in the Cycling Without Age Lanark County program.

I FURTHER ACKNOWLEDGE AND AGREE THAT I WILL NOT HOLD Cycling Without
Age Lanark County, its volunteers, officers or Directors responsible for any claim for
injury to property, person or reputation that may arise from media coverage or
publicity.

Passenger
Passenger First Name*   Passenger Last Name*      Date*   
Passenger Signature*   

Authorized Family Member or Legal Guardian
Authorized First Name*   Authorized Last Name*      Date*   
Authorized Signature*      

Witness
Witness First Name*   Witness Last Name*   
Witness Signature *   Date*