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Rider Registration Form
South Technical High School  12721 West Watson Rd., St. Louis MO 63127 
Monday, June 3 – Friday, June 7, 2018 
We are pleased to offer this bike program to people with disabilities and look forward to helping your family member learn to ride a two-wheel bicycle independently.
Requirements for Participation (Rider must meet Requirements for Participation (Rider must meet allall of below criteria):
●Minimum of 8 years of age
●Able to sidestep to both sides
●Have a disability
●Able to attend camp all 5 days
●Able to walk without assistive device
●Maximum weight 220 lbs.
●Willing and able to wear a properly fitted bike helmet
●Minimum inseam of 20” (measure from floorwhile rider is wearing sneakers)
***All fields are required. Registration will not be accepted if this form is incomplete.***
Rider/Family Information:
Rider Name: *
Your answer
Rider Gender (M or F): *
Your answer
Rider Date of Birth: *
MM
/
DD
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YYYY
Rider Height: *
Your answer
Rider Weight: *
Your answer
Rider Inseam (inches from floor while wearing sneakers): *
Your answer
Rider T-Shirt Size: *
Your answer
Rider Hand preference: L/R *
Your answer
Parent/Guardian Name: *
Your answer
Parent/Guardian Email: *
Your answer
Parent/Guardian Phone: *
Your answer
Parent/Guardian Cell Phone: *
Your answer
Home Address: *
Your answer
Emergency Contact Name & Phone Number: *
Your answer
Primary Diagnosis: *
Your answer
Secondary Diagnosis: (if any) *
Your answer
Please provide detailed information regarding the above diagnoses that will help us work with the rider effectively: *
Your answer
Rider Food Allergies (if any): *
Your answer
Please explain any health/medical conditions or health concerns or any special instructions needed: *
Your answer
*
Your answer
Choose a Session
Please number each session in order of preference. Only rank sessions you are able to attend. For example:
Session 1:
Session 2: 2nd
Session 3:
Session 4: 3rd
Session 5: 1st
Session #1: 8:30 am – 9:45 am, Session #2: 10:05 am – 11:20 am, Session #3: 11:40 am – 12:55 pm, Session #4: 2:00 pm – 3:15 pm, Session #5: 3:35 pm – 4:50 pm *
Your answer
Payment Information
Payment of the camp fee is required to process the registration form. Please mail check of $150 payable to Lydia Faith Cox Family Foundation to 714 Wildview Lane, Manchester, MO 63021 OR complete below Credit card information:
Name on credit card:
Your answer
Credit card #:
Your answer
Expiration Date:
Your answer
Security Code:
Your answer
Rider Information:
This information helps camp staff & volunteer spotters assigned to work directly with the Rider understand and better serve the individual needs of the Rider.
Rider Name: *
Your answer
Nickname (if any): *
Your answer
Age at time of camp: *
Your answer
Diagnosis: (optional)
Your answer
Please click the circle that most accurately describes your rider:
Generally speaking, the rider...
Can communicate his/her needs: *
When upset, can manage his/her emotions: *
Follows simple directions: *
Cooperates with others: *
Is comfortable with physical cues/prompts: *
Responds positively to playful banter: *
Benefits from pictures used to convey meaning: *
Gets frustrated easily: *
Has trouble staying focused: *
Gets upset by visual or auditory stimuli (e.g. bright lights or loud noises) *
Gets upset by background noise such as music or talking: *
Comments or additional information: *
Your answer
Please answer the following questions:
What strategies do you use to promote positive behavior and/or discourage negative behavior that will enable us to work safely and successfully with the rider? *
Your answer
What are favorite activities, movies, music, hobbies or other interests of the rider? *
Your answer
Has rider attended an iCan Bike program (formerly Lose The Training Wheels) previously? If yes, when and what was the outcome? *
Your answer
Has he/she ridden with training wheels? If yes, please provide a brief history. *
Your answer
Has rider experienced a bicycling accident? If yes, please explain. *
Your answer
Rider Liability Release:
By signing, I hereby expressly acknowledge that bicycling, like many sports such as swimming, golf, soccer, and gymnastics involves movement and physical activity, and that injury or mishap are possibilities in spite of a l reasonable safeguards and precautions taken. Further, I hereby expressly acknowledge that photographs and/or videos of the above rider may be taken by parties outside the control of Shine in connection with participating in bike camp. I acknowledge that Shine has limited or no control over such activities of third parties and has no control over any editing and/or use of such photos and/or video footage. As the parent/guardian of the above rider, I accept such risks as reasonable and proper, and agree to hold harmless the officers, principals, staff and volunteers of Lydia Faith Cox Family Foundation, iCan Shine, Inc., and Rainbow Trainers, Inc. should injury or mishap occur in this regard. I understand that data colected from this program wil be used to help the camp operate effectively relative to appropriate progressions, bike sizing and behavior management. I acknowledge that I may be contacted in the future for folow up information pertaining to rider progress, status or for other requests to support the future development and success of the program.
Rider Name: *
Your answer
Parent/Guardian Signature: (can be typed) *
Your answer
Photo Release:
I give permission for the above rider to be photographed and/or videotaped in print or electronic media by Shine or third parties acting on behalf of Shine. I acknowledge and agree that photographs and videos may be edited and used in whole or in part as desired for the purpose, which may be produced, duplicated, distributed and used for informational, promotional or other public purposes. I understand that photographs and video are not my property and there wil be no compensation to me. I understand and authorize the use in writing or otherwise the name or identity of the above rider.
Parent/Guardian Signature: (can be typed) *
Your answer
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