SPARC, a Chapter of DSUSA, Adaptive Cycling Rodeo for Kids
Saturday, October 21, 2017 -- 9:00 am to Noon
Bayside Baptist Church
6100 Highway 58, Harrison, TN 37341

The Adaptive Cycling Rodeo for Kids is a fun half-day event that includes:

• T-shirts for participants
• Bike Safety Clinic
• Proper helmet fitting
• Rules of the road

Refreshments will be provided.

Adaptive cycles will be provided for use by SPARC.

Registration Information
Last Name *
Your answer
Middle Name/Initial
Your answer
First Name *
Your answer
Participant Type *
Gender *
Date of Birth *
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Street Address *
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City *
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State *
Your answer
ZIP *
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Phone *
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E-mail Address *
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Contact Preference *
FOR PARTICIPANTS ONLY, please select a t-shirt size:
Guardian Information (Required if Participant is under the age of 18.)
NOTE: A separate liability form MUST be signed by a parent or legal guardian for every participant under the age of 18.
Relationship of Guardian to Participant
Name of Parent or Legal Guardian
Your answer
Emergency Phone Number for Parent or Legal Guardian
Your answer
Emergency/Medical Information
If a participant has a medical emergency at a SPARC-DSUSA event that requires treatment in addition to onsite first aid, the injured participant may be transported to a medical facility. The participant will be responsible for costs associated with transportation and medical care.
Name of Your Emergency Contact *
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Emergency Contact Phone # *
Please enter the best phone number to reach your emergency contact.
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Physician's Name
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Physician's Telephone Number
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Allergies *
Please enter "NONE" if you have no allergies
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Current Prescription Medications *
Please enter "NONE" if you are not currently taking any medications.
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Seizures *
Select "Yes" if you are prone to seizures.
Frequency of Seizures
Your answer
Date of Last Seizure
Your answer
Reporting Information *
Please select the most appropriate (you may select more than one).
Required
Military Veterans
Please complete the following:
Veteran Status
Please check all that apply:
Military Branch
Your answer
Wars Served
Your answer
Date of Injury
Your answer
Place of Injury
Your answer
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