Permission / Assumption Of Risk / Release Form Page 2
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3out of or in connection with such authorized emergency medical treatment.
I/We have consulted with a medical doctor with regard to my/our child’s personal medical needs. There are no
health-related reasons or problems that preclude or restrict my child’s participation in this Program. I/We have arranged,
through medical insurance or otherwise, to meet any and all needs for payment of medical costs while my/our child
participates in the Program.
Standards of Conduct:
My/our child will comply with the CBC rules, standards and instructions for youth behavior. I/We waive and
release all claims against CBC that arise at a time when my/our child is not under the direct supervision of CBC or that are
caused by my/our child’s failure to remain under such supervision or to comply with such rules, standards, and instructions.
I/We agree that CBC has the right to enforce the standards of conduct described above, in its sole judgment, and
that will impose sanctions, up to and including expulsion from the Program or from CBC, for violating these standards or for
any behavior detrimental to or incompatible with the interests, harmony, and welfare of CBC, the Program, the Facility or
other participants. CBC has the right to make changes in the format and administration of the Program.
Assumption of Risk, Covenant Not To Sue, and Release of Claims:
Knowing the risks described above, and in consideration of being permitted to participate in the Program, I/We
agree, on behalf of our family, heirs, and personal representative(s), to assume all the risks and responsibilities surrounding
my/our child’s participation in the Program. To the maximum extend permitted by law, I/We release, indemnify, and
covenant not to sue CBC from and against any present or future claim, loss or liability for injury to person or property which
my/our child may suffer, or for which my/our child may be liable to any other person, during his/her participation in the
Program.
I/We have carefully read this Release Form before signing it. No representations, statements, or
inducements, oral or written, apart from the foregoing written statement, have been made. The laws of the state of
Maine shall govern this agreement, which shall be the forum for any lawsuits filed under or incident to this agreement or to
the Program.
x_________________________________________ Signature of Youth Participant Date __________
x_________________________________________ Signature of Parent/Guardian Date__________
PHOTOGRAPH / VIDEO RELEASE
The Community Bicycle Center takes pictures or videos of people participating in various CBC
program activities. At times, photographers and camera operators from the news media will also take
images of the Community Bicycle Center participants. We need your permission to display these
images. We would like to use these images on bulletin boards in the CBC bike shop; in the Community
Bike Center literature and stationery; at conferences and workshops; and we would also like to use the
images to publicize the work of the participants in newspapers, magazines, professional publications,
and as part of the Community Bicycle Center website ( ).
____YES I grant permission for images to be taken of my child/ward and used for
display purposes outlined above
____ NO I do not grant permission for images to be used for display purposes nor on the
Community Bicycle Center website.
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