Bike Works · Bike Works Youth Participant Health and Medical History 2023/24

Contact Information

Youth Participant Name

*

First Name

Last Name

Youth Email

*

Verify Email

*

Youth Cell Phone

What school does youth currently attend?

*

Grade:

*

Date of Birth

*

(mm/dd/yyyy)

Address

*

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Pronouns

*

A pronoun is a word that refers to either the people talking (“I” or “you”) or someone or something that is being talked about (like “she”, “it”, “them”, and “this”). Gender pronouns (he/she/they/ze etc.) specifically refer to the person you are referring to.

Height

*

Gender Identity

*

Female

Male

Non-binary

Other (please specify)

Gender (Other)

Race/Ethnicity (check all that apply)

American Indian or Alaska Native

Asian or Asian American

Black or African American

Latine/Latinx/Hispanic

Native Hawaiian or other Pacific Islander

White or Caucasian

Mixed Race

Other (please specify)

Preferred Language(s)/Languages spoken at home:

*

Other (please specify)

Parent/Guardian Name

*

First Name

Last Name

Parent/Guardian Email

*

Verify Email

*

Parent/Guardian Phone

*

Parent/Guardian Pronouns

*

A pronoun is a word that refers to either the people talking (“I” or “you”) or someone or something that is being talked about (like “she”, “it”, “them”, and “this”). Gender pronouns (he/she/they/ze etc.) specifically refer to the person you are referring to.

Emergency Contact Information

at least one contact must be locally available, quickly and easily reachable by phone, and able to retrieve the participant during the course of the program

Emergency Contact #1

*

First Name

Last Name

Relationship

*

Address

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Phone #1

*

Phone #2

Emergency Contact #2

First Name

Last Name

Relationship

Address

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Phone #1

Phone #2

Physician/Clinic Information

MEDICAL AUTHORIZATION - SIGNATURE REQUIRED

Physician/Clinic Name

*

Physician/Clinic Phone

*

Insurance

Each Student is responsible for medical costs. Sickness and accident insurance is recommended but not required.

Do you have health insurance?

*

Yes

No

Insurance Company

Policy #

Insurance Phone

Does your insurance company require pre-authorization?

Yes

No

Medical History

Date of last tetanus inoculation:

*

(mm/dd/yyyy)

OTHER medical issues

Any checked boxes? Tell us more.

Allergic to any medications, or other allergies of any kind (latex, etc.) Please specify:

Allergic to food*/any food restrictions (specific food allergies, vegetarian, vegan, etc.):

Allergy to bee stings or insect bites*. Type of reaction:

Is the participant currently taking medication? If yes, please list (doseage, prescriptions, instructions, etc.)

Do you carry any medication in case of an emergency?

Any necessary medication must be in its original prescription container with a clear label detailing student's name, doctor's name & dosage instructions. * If yes, youth must have applicable medication in a clearly labeled prescription container with patient's name on it.

Accessibility

Does the participant have any disabilities that you would like Bike Works to know about?

Does the participant have any access needs you would like Bike Works to know about so that we can better accommodate their time and experiences here?

Does the participant utilize any mobility aids and/or sensory need aids?

Does the participant require the use of any adaptive cycling equipment in order to participate in bike programming or activities?

These could look like hand powered cycles, recumbent/recliner style bikes, tandem bikes where you could co-ride with a staff member and take breaks when needed, and tandem bikes that provide bodily support for participants who utilize wheelchairs.

Are there any other ways that we at Bike Works can be supportive during our time together?

Exercise

Check one for each

General Fitness Level

*

I don't exercise

Moderately active (30 min/week)

Active (30 min/day)

Very Active

Biking Ability

*

I don't bike

Beginner biker

Moderate biker

Strong biker

I Ride

*

Rarely

Once a Month

Once a Week

Every Day

Swimming Ability

*

We will not be swimming during 2022 summer camps.

Non-swimmer

Beginner

Moderate Swimmer

Strong Swimmer

Participant has a fear of water

*

Yes

No

MEDICAL AUTHORIZATION

SIGNATURE BELOW REQUIRED

In case of emergency, I hereby authorize and give permission to any physician, hospital, health care provider, or other medical personell selected by the staff of Bike Works to provide prompt medical treatment and arrange necessary related transportation for the participant. I agree that once the participant is in the care of medical personell or a medical facility, Bike Works shall have no further responsibility for the participant and I agree to pay all costs associated with such medical care and transportation. This completed form will be photocopied for the files of Bike Works.

The health history on this form is correct and not falsified to the best of our knowledge. I agree to allow Bike Works staff to dispense medications to the participant.

Do you consent to sign this form electronically?

*

If not, please contact us for a paper med-form.

Yes

No

Participant Signature

*

Parent/Guardian Signature - If participant under 18

*

PARENT/GUARDIAN WAIVER AND RELEASE OF LIABILITY

SIGNATURE BELOW REQUIRED

IN CONSIDERATION for my child/ward being permitted to participate in Bike Works Activities, I:

Acknowledge that I understand the nature of Bike Works’ sponsored Activities at and outside of Bike Works (“Activities”) and warrant that my child/ward is qualified, in good health, and in proper physical condition to participate in such Activities.
Acknowledge that some Activities occur on public roads and other facilities on which the risks of travel are to be expected and that some activities occur in a bike shop in which the risks of a shop setting are to be expected. These “RISKS” include MINOR INJURIES, SERIOUS BODILY INJURIES, PERMANENT DISABILITY, PARALYSIS, OR DEATH. These Risks may be caused by my child/ward’s actions or inactions as well as the actions or inactions of others participating in the Activities.
ACCEPT AND ASSUME ALL RISKS FOR LOSSES, COSTS AND DAMAGES I incur as a result of my child/ward’s participation in any Activities including any and all economic or non-economic damages not known to me nor readily foreseeable at this time.
RELEASE, COVENANT NOT TO SUE, and HOLD HARMLESS Bike Works, its volunteers, employees and sponsors, as well as other participants (“Releasees”) for any and all liability related to Activities caused or alleged to be caused in whole or in part by the Releasees. I further agree that if, despite this release, I, or anyone on my child/ward’s behalf, make such claim against any of the Releasees, I will indemnify and hold harmless the Releasees from any and all costs they incur as the result of such claim including, but not limited to, attorney fees and costs.
Periodically, Bike Works employees, affiliates, mentors and participants take pictures or videos while participating in various bicycle programs. At times, photographers and camera operators from the news media will also take images of Bike Works program participants. We need your permission to display these images. We would like to use these images for outreach, community publications and occasionally on the Bike Works website. Bike Works is careful about participants’ privacy and does not identify anyone by last name whenever a picture or view is used in any publicity materials. You may decline, however, to authorize your child/ward for these purposes.

I decline to authorize Bike Works to use images of my child/ward:

Check here if so

I HAVE READ THIS AGREEMENT, FULLY UNDERSTAND ITS TERMS, AND HAVE SIGNED IT FREELY AND WITHOUT ANY INDUCEMENT OR ASSURANCE OF ANY NATURE AND INTEND IT TO BE A COMPLETE AND UNCONDTIONAL RELEASE OF ALL LIABILITY TO THE GREATEST EXTENT ALLOWED BY LAW AND AGREE THAT IF ANY PORTION OF THIS AGREEMENT IS HELD TO BE INVALID THE BALANCE SHALL CONTINUE IN FULL FORCE AND EFFECT.

Do you consent to sign this form electronically?

*

If not, please contact us for a paper med-form.

Yes

No

Participant Signature

*

Parent/Guardian Signature - If participant under 18

*