2019 Ride for a Child Application
Thank you for your interest in the 2019 Ride for a Child program. Please fill out the questionnaire below. After submitting the questionnaire you should receive an email from colleen@pedalthecause.org with more information and next steps.
Child Information
Name (First & Last) *
Your answer
Birthdate *
Your answer
Diagnosis *
Your answer
Hobbies and Interest *
Your answer
Favorite Celebrity, Band, Sports Teams, Character *
Your answer
Briefly tell your child's story- you may touch upon details such as when was the child diagnosed, how this circumstance has impacted your family, how your family and child dealt with the circumstance, and what the future holds for your child. *
Your answer
Briefly describe your experience with Siteman Kids at St. Louis Children's Hospital and why you would like to participate in Pedal the Cause's Ride for a Child program? *
Your answer
Would you be interested in sharing your story in an interview? *
Parent/ Family Information
Parent/ Parents First & Last Names *
Your answer
Number of siblings *
Your answer
Names and ages of siblings
Your answer
Phone number *
Your answer
Email Address *
Your answer
Home Address *
Your answer
Facebook, caringbridge, or website page (if applicable)
Your answer
Please list the best way for your team to communicate with you (phone, email, text, facebook) *
Your answer
Ideally, how often would you like to receive communication from your RFC team
Please describe if your child has any food allergies or physical limitations.
Your answer
Child's T-Shirt Size- All sizes are unisex *
Siblings T-Shirt Size
Your answer
Parent(s) T-Shirt Size *
Your answer
Pedal the Cause Publicity Waiver
Participant understands that photographs, videos, recordings or voice likeness may be taken in connection with Pedal the Cause and irrevocably consents to such. Participant further grants permission to Pedal the Cause and its beneficiaries to publish, in any form, any photographs, videos, recordings or voice likeness of Participant participating in the Pedal the Cause and related Ride for a Child events. Participant further agrees that Participant is not entitled to any payment for any such and waives any right to inspect or approve the use of the photographs, videos, recordings or voice likeness, and acknowledges and agrees that the rights granted to this Publicity Waiver are without compensation of any kind.
By signing this form, I am agreeing to this waiver *
Your answer
Name of Participating Child Printed *
Your answer
Participant Parent/Legal Guardian Name Signed *
Your answer
Date *
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