Parent/Guardian Name
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First Name
Last Name
Email
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Parent/Guardian Phone Number
*
(###)
###
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What is your child's name?
*
What is your child's age?
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What school does your child attend?
*
Please select dates your child will join our bike train TO school:
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Please select the bike train depot your child will join at:
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Will you be bringing your child to the bike train depot?
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Please select dates your child will join our Bike train FROM school:
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Please select the bike train depot your child will return to:
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Will you be meeting your child at the bike train depot?
*
Emergency Contact Name/Relationship
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Emergency Contact Phone Number
*
(###)
###
####
Emergency Contact E-mail Address
*
Does you child have the following? (check all that apply)
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Event Waiver
RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF THE RISK AND INDEMNITY AGREEMENT AND CONSENT TO MEDICAL TREATMENT
By my signature below, I acknowledge that I am aware of, appreciate the character of, and voluntarily assume the risks involved in participating in:
Spearfish Bike Train
By my signature below, on behalf of myself, my heirs, next of kin, successors in interest, assigns, personal representatives, and agents, I hereby:
1. Waive any claim or cause of action against and release from liability the State of South Dakota, its officers, employees, and agents for any liability for injuries to my person or property resulting from my participation in the activity listed above;
2. Agree to indemnify and hold harmless the State of South Dakota, its officers, employees, and agents for any claims, causes of action, or liability to any other person arising from my participation in the activity listed above; and
3. Consent to receive any medical treatment deemed advisable during my participation in the activity listed above.
I HAVE READ THIS RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF THE RISK AND INDEMNITY AGREEMENT AND CONSENT TO MEDICAL TREATMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND HAVE SIGNED IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT, ASSURANCE, OR GUARANTEE BEING MADE TO ME AND INTEND MY SIGNATURE TO BE A COMPLETE AND UNCONDITIONAL RELEASE OF ALL LIABILITY TO THE GREATEST EXTENT ALLOWED BY LAW.
By checking the box below you acknowledge you have read the above waiver and you understand and agree to it's terms.
*
Photo Permission Waiver
SPEARFISH BIKE COLLECTIVE PHOTO RELEASE POLICY
By checking the box on our electronic registration form, you grant permission and consent to Spearfish Bike Collective (the “Releasee”) for the use of my likeness in a photograph, video, or any other digital media (hereby referred to as photos) in any and all presentations including but not limited to publications, including web-based publications, illustration, advertising, grant applications, without payment or other consideration.
Further:
I waive any right to inspect or approve the finished product wherein my likeness appears.
I understand that there shall be no payment for this release.
I understand that no royalty, fee, or other compensation shall become payable to me by reason of such use.
I understand and agree that all photos will become the property of Spearfish Bike Collective and will not be returned.
I understand that I may revoke this authorization at any time by notifying the Release in writing. The revocation will not affect any actions taken before the receipt of this written notification.
We, the Releasor and Releasee, understand and agree to the aforementioned terms and conditions.
I HAVE READ AND UNDERSTAND THE ABOVE RELEASE. I AFFIRM THAT I AM AT LEAST 18 YEARS OF AGE, OR, IF REGISTERING A MINOR, I GRANT THE REQUIRED CONSENT FOR MY CHILD(REN) AND SELF PARTICIPATING.
By checking the box below you acknowledge you have read the above waiver and you understand and agree to it's terms.
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First and Last Name (for photo release)
Date of Birth
MM
DD
YYYY
Address
Today's Date
*
MM
DD
YYYY
