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Easton Bike Club Registration
This is a high school program. FIX BIKES, RIDE BIKES, BUILD COMMUNITY. We offer this one month program in Easton High School. Please fill this form out with your parent or guardian.
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Which session would you like to participate?
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Participant's Name *
Date of Birth *
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Age *
Gender *
Address *
Zip *
Student Phone # *
School *
Grade *
I found Community Bike Works through *
Guardian's Name *
Relationship to Child *
Emergency Contact Name *
Parent/Guardian Contact Phone (Must be different from child) *
Email for student and/or guardian *
Is your child allergic to anything? *
If you answered yes to the previous question, please list
If your child has a food allergy, is he or she allergic to ingestion (eating it) or to contact (touching it)?  *
Does your child have any medical problems? *
If you answered "yes" to the previous question, please describe
The registering guardian recognizes bicycling is not an absolutely safe sport or transportation mode, and that accidents can and do occur, despite reasonable care. In considerations of the services to be rendered to the undersigned by Community Bike Works, the undersigned for him/herself and his/her heirs, personal representatives and assignees, hereby RELEASES and forever DISCHARGES Community Bike Works and all their employees and volunteers from any and all present and future claims, demands, obligations, liabilities, and rights of action of any nature whatsoever, whether known or unknown, which might be asserted against Community Bike Works and any of their employees or volunteers, related to or by reason of any occurrence, event, transaction, matter, cause, fact or thing arising from or in conjunction with bicycle instruction, bicycle training, bicycle repairs, bicycle mechanics, bicycle safety instruction, bicycle rides, bicycle tours, bicycle competition, any other bicycle related activity, or any other activity or field trip conducted under the supervision of Community Bike Works.  *
The participant named above has my permission to participate in the events listed above. I give this permission as their parent or guardian. *
I grant Community Bike Works and/or its designates permission to use and/or publish any and all photographs and/or videos taken during all Community Bike Works' activities. *
I will require the participant named above to wear a helmet whenever riding a bicycle. *
In the event of an emergency, I give representatives of Community Bike Works the power to authorize medical care for the participant named above. *
Ethnicity *
Race (please select one or more statements which best describe your racial composition) *
Required
Household Size *
Income *
Is a female the head of your household *
Do you have a disability? *
I hereby certify that all the information is true and accurate. *
Required
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