Permission / Assumption Of Risk / Release Form

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PERMISSION / ASSUMPTION OF RISK / RELEASE FORM
THIS IS A RELEASE OF LEGAL RIGHTS -- READ AND UNDERSTAND BEFORE SIGNING.
Name of Participant_____________________________________ Date____________________
Age_____Birthdate____________________M___F___ School __________________________
Parent/Guardian________________________Home Address_____________________Apt.#___
City/Town_____________________________Zipcode_________________________________
Home Phone________________Work Phone________________Cell Phone________________
Participant Cell Phone_____________________________________________________________
Participant E-mail address___________________________________________________________
Guardian E-mail address____________________________________________________________
Alternate Contact_________________________ Relationship__________Phone_____________
I hereby give permission for the above named child ______________________________ to participate in Community
Bicycle Center programs. Programs include Out/After School Drop in Bicycle Repair and Maintenance, on and off
road Group Bicycle Riding, and Community Service projects. Participation in CBC programs may include
swimming, fundraising, and going to public places. I hereby agree as follows:
Risks of Participation: I fully recognize that there are dangers and risks to which my/our child may be exposed by
participating in Community Bicycle Center programs.
1 More specifically, I/We acknowledge and accept the following: There exists the possibility of sustaining minor
injuries including sunburn, dehydration and sore feet/muscles as well as major injuries up to and including
broken bones and even death as a result of participating in any of the activities in this program.
2 I/We accept full responsibility for any injuries or illness that my/our child may sustain in the course of the
Program activities. I/We understand that the Community Bicycle Center, its board of directors, staff
employees, and volunteers (collectively “CBC”) do not require my/our child to participate in the Program, but
I/We want my/our child to do so, despite the possible dangers and risks and despite this Release. I/We therefore
agree to assume and take on all of the risks and responsibilities in any way associated with the Program.
Health & Safety:
I/We understand and agree that CBC does not have medical personnel available at the Facilities, which are the site
locations for participation in the Program. I/We understand and agree that CBC is granted permission to authorize
emergency medical treatment for my/our child, if necessary, and that such action by CBC shall be subject to the terms of this
Agreement. I/We understand and agree that CBC assumes no responsibility for any injury, damage or cost which might arise
1

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