Walk 'n Rollers Bicycle Request Application
Use this form to request a used bicycle. Limit 2 per family. The number of bicycles, sizes, color and styles are limited and all bikes are in as-is condition. Walk 'n Rollers will contact you directly when a bicycle is ready for pickup. Walk 'n Rollers is unable to deliver bicycles. Please be sure you are able to arrange for pickup.
Parent First Name *
Your answer
Parent Last Name *
Your answer
Parent e-mail *
Your answer
Phone *
Your answer
Address *
Your answer
City *
Your answer
Zip Code *
Your answer
Number of bIkes (limit 2) *
Age of Child 1 *
Your answer
My child is a: *
Height of Child 1 *
Your answer
Weight of Child 1 *
Your answer
Age of Child 2
Your answer
My child is a:
Height of Child 2
Your answer
Weight of Child 2
Your answer
I understand that Walk 'n Rollers is unable to deliver bicycles. I agree to pickup the bike within 7 days of being notified or risk losing the bicycle. *
Required
I have read and agree to the following: 1) I ACCEPT THE BICYCLE FOR USE AS IS. I have made no misrepresentations to Walk ‘n Rollers in any regard, including, but not limited to, my/my child’s height, weight, age, abilities, or bicycle type. 2) For donated bikes, I understand I will not have the opportunity to request a specific bicycle in regards to type, style, color or size and that Walk 'n Rollers will use it's best judgement in acquiring an appropriate bicycle based on the information I have provided above. Further, I have the right to refuse any bicycle offered by Walk 'n Rollers and am under no obligation to take delivery of the used bicycle. 3) I understand that the risks of bicycles are numerous and include, but are not limited to, the following: DEATH, PARALYSIS, HEAD INJURIES, BROKEN BONES, CUTS, SCRAPES, DAMAGE TO BIKES, GEAR, AND CLOTHING, AND CAUSING DAMAGE TO AND/OR INJURING OTHERS; falling; loss of control; encountering trees, limbs, brush, rocks, structures, ropes, barriers, or other man-made or naturally occurring obstacles; encountering unpredictable terrains such as varying steepness, mud, holes, cliffs, gravel, narrow trails, and/or lack of trails; negligence of other riders, persons, or vehicles. 4) I take full responsibility for my or my child's use of any bicycle offered by Walk 'n Rollers, and agree to adhere to all state and local laws in regards to BIKE HELMETS, ROAD SAFETY and TRAFFIC LAWS. 5) I have a helmet or will acquire one before I or my child ride the bicycle. I will wear a helmet every time I/my child ride(s) this bicycle. I understand that wearing a helmet may decrease the risk of head injury and that it is the law in California to wear a helmet if you are under the age of 18. 6). I agree that Walk ‘n Rollers will not be responsible for any unsafe use or any violations of the terms of this agreement and waiver. 7) I have checked the bike for damage and I agree that the bicycle is in AS IS condition and that Walk ‘n Rollers is not responsible for the condition of the bicycle or it’s parts. 8) I understand that Walk ‘n Rollers recommends having the bicycle inspected by a professional bicycle mechanic before I/my child ride(s) it. 9) I AGREE TO FULLY RELEASE AND DISCHARGE WALK ‘N ROLLERS FROM ANY LIABILITY for any damages, injuries, or claims, including any injuries or damages occurring from any negligence to myself, my child or any other person or property, as a result my participation in bicycle use. I fully understand and agree to release Walk ‘n Rollers for its negligence in causing in whole or in part any injury to me. 10) I EXPRESSLY ASSUME ALL RISK OF LOSS, DAMAGE OR INJURY OCCURRING AS A RESULT OF PARTICIPATING IN USAGE, AND/OR BICYCLE RIDING, INCLUDING THE RISK OF WALK ‘N ROLLERS NEGLIGENCE. 11) Promise Not to Sue and Hold Harmless. 12) AGREE NO LAWSUIT WILL BE FILED BY ME OR ON MY BEHALF AGAINST WALK ‘N ROLLERS as a result of my participation in riding the purchased/donated bicycle. If I do file a lawsuit, I agree to pay any attorney fees, costs or judgments incurred by Walk ‘n Rollers even if Walk ‘n Rollers is found negligent. I FURTHER AGREE TO INDEMNIFY Walk ‘n Rollers AND HOLD IT HARMLESS FOR ANY DAMAGES, INJURIES, JUDGEMENTS OR LAWSUITS, including any attorney’s fees and costs incurred by Walk ‘n Rollers as a result of my use of the bicycle or any lawsuits resulting from my use. I agree my obligation to indemnify and hold harmless applies even if Walk ‘n Rollers is negligent. 13) I understand this is a contract, which limits my legal rights, and it is binding upon me, my heirs and legal representative. If portions of this agreement are invalid, it is agreed the remaining portions will remain intact and enforceable. By signing or reading the Release of Liability, the undersigned acknowledges she or he has fully read and understands the above and foregoing. 14) All Riders under the age of 18 years are required to have a parent or legal guardian read and also sign this Release: The parent and the Rider have read, understand and agree to comply with this Release. 15) By signing this document, the parent or guardian agrees to each of the provisions above, including to indemnify and hold Walk ‘n Rollers its agents or employees harmless from any and all claims brought by the Rider or resulting from the Rider’s actions, whether Walk ‘n Rollers, its agents or employees are negligent or not. *
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