iCan Bike Participant Application Form
Cost of program: (helmet & t-shirt included)

$25 application fee (Due upon completion of your application. This fee is
non-refundable unless we are unable to accommodate your rider. Application
fee will be applied towards total cost of camp.)

$50 for Foundation "Family Members"
$150 for Foundation "Community Members" and non-members

Once your participation is confirmed you will have 10 days to submit your payment.

Award Letters will be sent out by July 1, 2019.

Personal Information
Participant First Name: *
Your answer
Last Name: *
Your answer
Gender: *
Your answer
Date of Birth: *
MM/DD/YYYY
Your answer
Age: *
Your answer
Parent/Guardian First Name: *
Your answer
Last Name: *
Your answer
Email Address: *
Your answer
Home Phone: *
Your answer
Work Phone: *
Your answer
Cell Phone: *
Your answer
Preferred method of contact: *
Street Address 1: *
Your answer
Street Address 2:
Your answer
City: *
Your answer
State: *
Your answer
Zip: *
Your answer
Emergency Contact Name: *
Your answer
Emergency Contact Number: *
Your answer
Physical Information
Height: *
Please provide feet and inches. Actual measurement needed.
Your answer
Weight *
(in pounds)
Your answer
Inseam: *
(in inches measured from the floor -- actual measurement needed)
Your answer
Helmet size: *
T-shirt size: *
Additional shirts are $10.
Please indicate size and quantity. Payment due with registration.
Unique Ability Information
Primary Diagnosis *
Your answer
Secondary Diagnosis
Your answer
Please provide info about the participant that will help us work with the him/her effectively:
Your answer
Medical Information
Food Allergies: *
If yes, please explain:
Your answer
Please explain any other medical conditions:
Your answer
Choose a Session
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
Please list your top 3 choices. *
Your answer
Will you be able to attend all five days of camp? *
How did you learn about iCan Bike? *
Your answer
PHOTOGRAPH AND/OR VIDEO RELEASE
I give permission for the above rider to be photographed and/or videotaped in print or electronic media by Down Syndrome Foundation of Florida or third parties acting on behalf of Down Syndrome Foundation of Florida. 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 will be no compensation to me. I understand and authorize the use in writing or otherwise the name or identity of the above rider.
I am a parent/guardian. I have read the above and fully understand its contents. *
*
*
iCan Bike Program Description
The objective of iCan Bike is to teach individuals with disabilities to ride a
conventional two wheel bicycle without training wheels.

Our program uses specialized equipment, coaching and encouragement to reach this
goal. Through the use of our equipment, we gradually introduce the instability
of the bicycle until the participant “discovers” how to ride a bike.

Staff from iCan Bike, in partnership with Insert your organization name, conduct the
program. The iCan Bike staff will supervise the progress of the participants and
direct the work of volunteer “spotters”. They will also make necessary adjustments
to the trainer bikes for each participant.

Participants will attend one session (75 minutes) per day for a total of five days. During the session each participant will ride indoors on an adapted trainer bike or outdoors on a conventional bike once they have achieved that skill level. Participants are required to wear a properly fitting helmet when they are on a bike.

Bicycling involves a physical activity on moving equipment. It is inevitable that circumstances will arise when it is necessary to physically touch, hold, or even grab your participant. This often occurs as we place feet on pedals, lift a chin to improve forward vision, place a hand on the back to increase pedaling speed, or catch a participant who might be falling. These activities occur in a public setting and are for therapy purposes. If you or your participant objects to being touched you are advised to not enroll in this program.

In spite of extensive safety measures, bicycling involves the risk that a participant will fall or collide with an obstacle or another rider. The result of a fall or collision could be a mild injury such as a skinned knee or a serious injury such as a broken bone or head injury. By enrolling in this program you acknowledge that you are aware of, understand and accept this risk.

We strive to teach every participant to become an independent bike rider, but we are not successful in all cases. The outcome cannot be predicted and is not guaranteed. We do promise to make every effort to provide the best equipment, staff and environment to assure each participant’s highest level of success possible.

Rider Information
Please provide the following information for use by camp staff & volunteer spotters.
Rider's Name: *
Your answer
Nickname: *
Your answer
Age: *
Your answer
Can communicate his/her needs *
Gets frustrated easily *
When upset can manage his/her emotions *
Consistently follows simple directions *
Cooperates with others *
Is okay to be touched to help re-direct *
Is okay to be touched to express joy or comfort *
Likes to be playfully teased *
Has trouble staying focused *
Gets upset by loud, sudden noises *
Gets upset by background noise such as music or talking *
Benefits by using pictures to convey meaning *
Is fearful about riding a bike *
What strategy do you use to promote positive behavior and/or discourage negative behavior ? *
This information will enable staff 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
Please provide a brief bike riding history. *
(Training wheels? Accidents? Previously attended iCan Bike camp (including result)?, etc.)
Your answer
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This form was created inside of Down Syndrome Foundation Of Florida.