Tracy Bike Life - Youth Program
Please fill out registration form completely. Students must be 7 to 17 years old and permission is required by parent/guardian. 

Classes are held at Clyde Bland Park 1753 Blandford Ln, Tracy, CA 95377 every Tuesday from 5-7:00 pm and run for 6 weeks.

Due to high demand, classes are limited! If classes are full,  students will be placed on a waiting list. Please let us know if your child is unable to to attend the session, so we may accommodate the next in line.

If you have any questions, you can email us at info@tracyearthproject.org. We look forward to working with your child as he/she learns the transformative power of a bike!

*Children do not need to know how to ride a bike in order to participate, but we are unable to provide lessons.

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Email *
BASIC INFO
Which session are you enrolling in?

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Child's First and Last Name
 *
Child's Age *
Parent's First and Last Name
 *
Parent's Phone Number with Area Code
 *
Parent's Email
 *
Address and City
 *
Emergency Contact #1 Name
 *
Emergency Contact #1 Phone Number with Area Code *
May child be released to Emergency Contact #1? *
Emergency Contact #2 Name
Emergency Contact #2 Phone Number with Area Code
May child be released to Emergency Contact #2?
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If your child has any allergies (i.e., nuts, strawberries, latex), please explain.
If your child has a health issue or takes any medication that we should be aware of (i.e., asthma inhaler, Epi-pen, seizure disorder, ADHD), please explain.
DEMOGRAPHICS
The next few questions are about demographics. Your answers help us understand the needs of the kids we serve and make our program better. We will NEVER share your information with ANYONE.
Child's Gender  
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Child's Race/Ethnicity
Check ALL that apply.
HOUSEHOLD INFO
Tracy Bike Life Youth Program receives grants from the government, so we are required to collect proof of income. 

Parents must bring proof of income on the first day of class. Examples of acceptable proof are paystubs, tax returns, W-2, 1099, passport to services, social security award letter, self-employment certification, etc. If you can't get any of these, please send an email to info@tracyearthproject.org and we will be happy to work with you.

Again, we will NEVER share your information with ANYONE.
Total MONTHLY Household Income *
Proof of income required on first day of class. 
Total Number of People in Household *
PARENT PERMISSIONS
Parents must sign paperwork on the first day of class.
Does Tracy Bike Life Youth Program (TBLYP) have permission to use your child’s photo in video and publications, for the purpose of advertising and promoting TBLYP? *
Does your child have permission to go on group bike rides, under the supervision of at least 2 instructors? *
I give permission for my child to participate in the TBLYP. I will not hold any person or agency connected with TBLYP responsible for loss or harm, including injury to my child during his/her participation in the program. 

I understand that TBLYP's liability insurance coverage is exclusive to students only while in attendance at Tracy Bike Life Youth Program Classes, during the times allocated on each student’s schedule and ending at graduation.

Parents, by typing your full name below, you are providing consent. *
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