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