NBW YOUTH APPLICATION WAIVER

Guardian information

Primary Phone Type
Secondary Phone Type
Preferred Contact Method
Guardian Relationship to Participant
Public assistance eligible
My family is eligible to receive some form of public assistance, such as food stamps, cash assistance, or low-income heating support.

Please help us gather info for our funders so NBW youth programs can remain free, or low cost. Your individual answer will not be shared - it will contribute to an aggregate percentage.

YOUTH INFO

I'm interested in (check all that apply):
Height
NBW has permission to contact the participant by (check all that apply):
I identify my gender as (check all that apply):
Please help us ensure our programs are serving everyone, equitably.
I identify my race as (check all that apply):
Please help us ensure our programs are serving everyone, equitably.

HEALTH & SAFETY

May NBW staff administer Benadryl if the participant is experiencing an allergic reaction?
Does the participant have and use an asthma inhaler on a daily basis?
NBW is NOT responsible for administering medications. However, we will share this information with medical professionals in case of a medical emergency.
May the participant wade in water while supervised by NBW staff?
Is the participant able to ride a bike?
Is the participant able to ride for 20 minutes at a reasonable pace without rest?

EMERGENCY CONTACT INFO

TRANSPORTATION

May the participant leave NBW activities by themselves?
May the participant leave NBW activities on a bicycle by themselves?
May the participant take SEPTA with NBW for activities?
Does the participant have a weekly transit pass provided by their school?
NBW is able to provide tokens to program participants so they can safely return home. Will the participant need a token at the end of NBW classes and activities?

WORD ON THE STREET

How did your family hear about NBW? (check all that apply):

LIABILITY WAIVER

The undersigned hereby recognizes that bicycling and bicycle repair are not absolutely safe, and that accidents can and do occur, including injuries that may be serious and permanent, despite all reasonable care.

In consideration of the services to be rendered to the undersigned by Neighborhood Bike Works Inc. (referred to herein as “Neighborhood Bike Works), the undersigned for themselves and their heirs, personal representatives and assignees, expressly releases, waives and covenants not to sue Neighborhood Bike Works, its shareholders, members, officers, directors, partners, employees, agents, volunteers, successors and assigns (“Released Parties”), with respect to any liability for injury, death, property loss, claim(s), demand(s), cause(s) of action, damage(s), loss or expense, including court costs and reasonable attorneys’ fees, of any kind or nature which may arise out of, result from or is related to bicycle instruction, bicycle training, bicycle repairs, bicycle mechanics, bicycle safety instruction, bicycle rides, bicycle tours, bicycle competition, or any other indoor or outdoor activity or field trip conducted under the supervision of Neighborhood Bike Works, including claims for liability caused in whole or in part by the negligence of any of the Released Parties. The undersigned further agrees that if they, or anyone on their behalf makes a claim for liability against the Released Parties, they will indemnify, defend and hold harmless each of the Released Parties from any such liability that may be incurred as a result of such claim.

By signing this form, the undersigned, being a person of at least eighteen (18) years of age acting on behalf of the following Participant as Self, Parent, or Guardian, I acknowledge my understanding of the foregoing, that I am signing this form voluntarily, and that I give Neighborhood Bike Works and any of their employees, volunteers, successors, assigns, trustees, officers, and agents the power to authorize medical care for the participant. I also acknowledge that the participant should properly use a bicycle helmet whenever riding a bicycle.

 
As the legal Parent/Guardian of the Participant, by typing your full name below, you are providing your signature.

MEDIA & FEEDBACK RELEASE

In consideration of the opportunity to participate in the programs offered by Neighborhood Bike Works I, hereby give permission to Neighborhood Bike Works, its employees, affiliates, representatives, contractors, agents and members of the media to interview, audiotape, photograph, videotape, film, or capture by any other electronic means my/my child’s image and speech, and, within its absolute discretion, to release, disseminate, or use, in any manner it sees fit including publications and web pages, the resulting images and testimonials and any other information contained therein for the purpose of promoting the objective of Neighborhood Bike Works. This includes the release of feedback and information as collected through surveys and evaluations for the purpose of program evaluation.
Consent to Media & Feedback Release:

HAVE QUESTIONS FOR US?

A copy of your responses will be emailed to the address you provided.